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PAUL B. HOEBER, 69 East 59th St., N. Y. 



DIET AND HYGIENE 



IN 



Diseases of the Skin 



BV 

Lf DUNCAN BULKLEY, A.M., M.D. 

PHYSICIAN TO THE NEW YORK SKIN AND CANCER HOSPITAL; CONSULTING PHYSICIAN TO 

THE NEW YORK HOSPITAL*, [CONSULTING DERMATOLOGIST TO RANDALL'S 

ISLAND HOSPITAL, TO THE HOSPITAL EOR RUPTURED AND 

CRIPPLED, AND TO THE MANHATTAN EYE 

AND EAR HOSPITAL, ETC. 




NEW YORK 
PAUL B. HOEBER 

69 East 59th Street 



RL72 

.BS5 



Copyright 

1913 
PAUL B. HOEBER 



Jr *~ t 



Q 



©CLA330788 



33r 



TO 
THE MANY PHYSICIANS 

WHO HAVE HONORED ME BY THEIR FAITHFUL 

ATTENDANCE AT AND INTEREST IN MY 

CLINICAL LECTURES ON 

DISEASES OF THE SKIN 

FOR NEARLY FORTY YEARS THIS THIRD 

VOLUME IS RESPECTFULLY 

DEDICATED 



PREFACE 

As in the case of my former series of lectures "On 
the Relations of Diseases of the Skin to Internal Disor- 
ders," and on the "Principles and Application of Local 
Treatment in Diseases of the Skin," these lectures are 
largely of a personal character, reflecting the experience 
of the writer, for the benefit primarily of those who have 
attended the Clinical Lectures at the New York Skin 
and Cancer Hospital. While recognizing the immense 
importance of diet and hygiene in connection with very 
many diseases of the skin, it is quite impossible during 
the brief hour of a clinical lecture to inquire into or to 
give careful directions concerning these matters to the 
patient, which would also be for the benefit of those at- 
tending the lectures: hence the subjects were treated of 
specially in six lectures at the end of the course. 

In preparing these lectures the attempt was made not 
only to crystallize my own personal views and expe- 
riences along the lines of diet and hygiene in diseases of 
the skin, as observed mainly in private practice, but also 
to add scientific support from the vast and ever increas- 
ing literature dealing with the chemistry of foods and 
nutrition. It was quite impossible, however, to attempt 

vii 



viii PREFACE 

to enter the journalistic literature, and one had to be 
content to utilize standard works and monographs, 
which are mentioned in the Bibliography. 

With all that has been written in regard to the rela- 
tion of food to nutrition, we must confess that we are 
yet very far from understanding some of even the 
simplest propositions concerning metabolism; and the 
scientific basis of our knowledge and action must be 
more or less uncertain until our knowledge of physi- 
ological chemistry is more perfect. 

But the science of medicine is built up slowly by both 
clinical observations and laboratory studies, and in these 
lectures I have endeavored to make at least some small 
clinical contribution of matters which I have verified so 
continually for years in private practice, that I have no 
hesitancy in advocating the measures suggested. How 
much farther it will be possible to determine the dietetic 
relations of the diseases mentioned, or others, depends 
upon the careful observation and assiduous note-taking 
of the many now engaged in the practice of dermatol- 
ogy; for these questions will never be settled by the 
laboratory alone. The sooner and the more thoroughly 
the thought and attention, and work of those engaged in 
this branch of medicine is turned from purely local 
pathology and treatment, to the consideration of the 
deeper and fundamental elements of tissue disturbance 
from internal causes, the better it will be for science and 
for the practical relief of sufferers from many diseases 



PREFACE ix 

of the skin. Every intelligent layman recognizes that 
what is eaten and drunk must have much to do with the 
character and integrity of the tissues of which it goes 
to form a part, and the profession should be more alive 
to study and observe the internal relations of many 
maladies which appear upon the skin. The intimate 
analytical study of the urine from time to time, by volu- 
metric methods, often throws the strongest light upon 
the anabolism and catabolism of the system, which are 
in turn affected so greatly by the diet. 

In the Appendix I have endeavored to be even more 
practical and definite, and have outlined a dietary with 
the exclusion of animal food, which often seems so very 
desirable in certain diseases of the skin. When such 
a diet is proposed very many object strongly, and can- 
not realize the great abundance and variety of the prod- 
ucts of the ground, which can perfectly supply all the 
needs of the system ; in the menus presented I have en- 
deavored to include a very great diversity of cereals and 
other vegetarian products from which a choice can be 
made. 

In presenting this little book to the profession I 
recognize only too well that it comes far from what 
could be wished. But as a pioneer work in this much 
neglected branch of dermatological therapeutics I be- 
speak for it a kindly criticism. There is very little def- 
inite in regard to the subjects to be found in the standard 
works on diseases of the skin, and as far as I know, rel- 



x PREFACE 

atively little in current literature, consequently there is 
little reference to the work of others in this line. 

Of the matters concerning which I speak positively 
I am so fully convinced from observation in innumerable 
cases that I can only add that I trust that many others 
will put them to the test. In regard to the basic idea 
of this book, that metabolism, as influenced by diet and 
hygiene, can have the greatest effect upon the structure 
and diseases of the tissues of the body, including the 
skin, there can be no doubt. The hope is that this work 
may be the means of directing many others to study and 
record the effects of diet and hygiene in this class of dis- 
eases, and that the matter here contained may be the 
means of aiding many in overcoming certain diseases of 
the skin which are often so very obstinate. 

531 Madison Ave. 



CONTENTS 



LECTURE I 

PAGE 

The Rebelliousness and Recurrence of Many Cutane- 
ous Affections Indicate Some Underlying Cause — 
Even Tubercle Bacilli and Pus Organisms Require 
a Proper Soil — Faulty Metabolism and Auto-in- 
toxication often Found with Skin Lesions — De- 
pendence of These upon Diet — Errors of Diet and 
Mode of Their Operation upon the Skin — Over- 
eating and Wrong Eating — Gratifying the Taste 
after the Appetite is Satisfied — Definition of Diet 
— Elements Affecting Digestion: Mental and 
Nervous Influence — Mastication, Insalivation, 
Fletcherism 3 

LECTURE II 

Nutrition as Indicated by Repeated Volumetric Uri- 
nary Analysis — Danger Signals from the Skin — 
Excess of Nitrogen in the Food often at Fault — 
Vegetarian Diet May Even Have This in Beans, 
Peas, and Lentils — Fish and Shell-fish — Spiced 
Foods — Vinegar — Nuts — Sweets — Fruits — Dried 
Fruits — Tea, Coffee, Cocoa, and Chocolate — Alco- 
hol, Influence on the Skin — Alcoholic Drinks, 
Harmfulness in Syphilis and Many Dermatoses. . 23 

LECTURE III 

Liquid Needed for Digestion — Mineral Springs — Value 
of Beverages; Harm from Cold Drinks — Milk 

xi 



xii CONTENTS 

PAGE 

Harmful in Many Cutaneous Affections, Errors 
in Taking — Correct Method of Taking — Absorp- 
tion versus Digestion of Milk; Physiological Ex- 
planation — "Alkaline Tide" — Good and Bad Cook- 
ing of Food: Combinations — Diet in Relation to 
Age and Activity — Vegetarianism 43 

LECTURE IV 

Diet in Eczema — Acute Eczema, Tea, Coffee, Tobacco — 
— Rice Diet Controlling Acute Eczema and In- 
flammatory Cutaneous Affections — Rationale of 
Dietary Treatment: Duration — Infantile Eczema 
— Wheat Jelly — Rationale — Errors in Diet of In- 
fants with Eczema — Health of Nursing Mothers 
— Diet in Chronic Eczema 65 

LECTURE V 

Acne, Dietary Causations, Errors in Diet— Acne Juve- 
nilis, Less a Matter of Age than of Erroneous 
Diet — Rapid Eating, and Imperfect Mastication — 
Milk with Food Harmful — Acne Rosacea, Harm- 
fulness of Alcoholic and Fermented Drinks — 
Psoriasis, Effect of Diet — Results from Vegeta- 
rian Diet — Error Exploded in Regard to Passa- 
vant's So-called Meat Diet — Explanation of Basis 
for Vegetarian Diet — Duration of the Same — 
Urticaria, Acute Lichen Planus, Furunculosis, 
Mycosis Fungoides, Epithelioma, Alopecia, Syph- 
ilis, as Influenced by Diet 87 

LECTURE VI 

Importance of Proper Hygiene in Diseases of the Skin : 
— Regularity of Life — Importance of Regular and 
Effective Action of the Bowels — Sleep in Rela- 
tion to Diseases of the Skin — Rest, Exercise, 
Massage, Occupation, Atmospheric Conditions — 



CONTENTS xiii 

PAGE 

Clothing, Bathing, Turkish and Russian Baths, 
Sulphur and Mercurial Baths, Sea Bathing, Ef- 
fect on Diseases of the Skin — Mineral Springs, 
Errors in Regard to, and Relative Uselessness of 
— Classified List of Mineral Springs, with Indica- 
tion for Their Use 113 

APPENDIX 

Special Diets — Cautions as to Dietary Directions — 
Nitrogen Free Diet — "Rice Diet" — Purin Free or 
Largely Vegetarian Diet — Table of Vegetarian 
Foods, with Fuel Values — Menus for Ten Days, 
Vegetarian Diet — Light Mixed Diet — Table of Ni- 
trogenous Foods, with Fuel Values 149 

Bibliography 173 

Index 179 



LECTURE I 



DIET AND HYGIENE IN DISEASES 
OF THE SKIN 

LECTURE I 

The rebelliousness and recurrence of many cutaneous affections 
indicate some underlying cause. — Even tubercle bacilli and 
pus organisms require a proper soil. — Faulty metabolism and 
auto-intoxication often found with skin lesions. — Depend- 
ence of these upon diet. — Errors of diet and mode of their 
operation upon the skin. — Overeating and wrong eating. — 
Gratifying the taste after the appetite is satisfied. — Definition 
of diet, — Elements affecting digestion: mental and nervous 
influence. — Mastication, insalivation, Fletcherism. 

Gentlemen : — 

Diseases of the skin as a class are notoriously rebel- 
lious, and some cases tax the skill and patience even of 
the specialist to an annoying degree. We are yet far 
from understanding many of them as well as we would 
like, and in some instances they seem almost incurable. 

But there is a cause for everything in this world, 
and human skill and discernment are gradually probing 
nature, so that the science and art of medicine has pro- 
gressed incomparably of late years, along the lines of 



4 DIET AND HYGIENE IN 

both etiology and treatment. There is still, however, 
much regarding many diseases of the skin yet to be 
learned, both as to their causation, persistency, and 
proneness to recur : and it is no great wonder that they 
should have these latter characteristics if we do not 
reach and rectify their underlying causes. 

I say underlying causes, for while I recognize fully 
the local agencies, parasitic, microbic, and others, which 
may directly excite or even produce certain lesions on 
the skin, I recognize also the fact that there must be 
some condition of system or tissues, which often escapes 
detection, which either renders the skin susceptible to 
many of these influences or directly excites it to disease 
now and again; for but few of the diseases appearing 
on the skin are like small-pox, in which the poison se- 
cures immunity from another attack. We have learned 
that all of us are exposed to the infection of tubercu- 
losis almost daily, and yet few are seriously affected, 
and in like manner pus cocci are well-nigh omnipresent, 
though relatively few are afflicted with boils, carbuncles, 
or pus infections. In many affections of the skin there 
is absolutely no reasonable indication that local agencies 
play any causative part in their occurrence. 

It will be the object of these lectures to make as clear 
as possible the relations which exist between diet and 
hygiene and many diseases of the skin, both from an 
etiological and therapeutic standpoint. 

A large proportion of the actual cases of disease ap- 



DISEASES OF THE SKIN 5 

pearing upon the skin have more or less to do with the 
nutritive processes which are continually going on 
within the body, and are to a greater or less degree af- 
fected by metabolism; this has been shown by many, 
and was the special topic of discussion at the 5th Inter- 
national Dermatological Congress, in Berlin, in 1904, 
with a number of papers on the subject. 

In order to understand properly the basis of diet and 
hygiene in diseases of the skin it may be well to quote 
the conclusions presented by the present writer on that 
occasion, 1 and confirmed by others present: 

1. Metabolism represents the series of chemico-phys- 
iological changes occurring within the system, by means 
of which, first by anabolism, nutritive material and oxy- 
gen are converted into an integral part of living tissues ; 
and, second, catabolism, whereby their potential energy 
is expended in living force and heat, and the products 
of the physiological disintegration of tissue are rejected, 
in altered form, and appear in the excreta. 

2. As healthy cell action and transformation is pro- 
duced and maintained by perfect metabolism, so when 
there is perverted metabolism the structures in various 
parts of the body must suffer, and this we call disease, of 
the skin or other parts of the economy. 

3. As every cell in the body constantly takes up and 
gives off material, so the results of metabolism can be 

1 Bulkley. Diseases of the skin connected with errors of Metabolism. 
Medical Record, Nov. 26, 1904. 



6 DIET AND HYGIENE IN 

affected by the normal or abnormal action of every liv- 
ing cell in the organism. 

4. Metabolism is, however, principally affected by 1, 
the kind of nutriment taken; 2, the action of the diges- 
tive organs and ductless glands; and, 3, the action of 
the nervous system. 

5. Certain skin lesions, or eruptions, have been cred- 
ibly reported as connected with or dependent upon the 
generally recognized metabolic conditions of, 1, Gout: 
2, Rheumatoid arthritis: 3, Diabetes: 4, Obesity: 5, 
Scrofulosis. 

6. As yet no absolute statement can be made as to 
the necessary connection of the two, for the same erup- 
tions occur in connection with several of the metabolic 
conditions. 

7. The idiosyncrasy of the patient, and many causative 
elements, external or internal, nervous, etc., often de- 
termine which form of skin disturbance or alteration 
shall take place. 

8. Errors of diet, disorders of digestion, faulty excre- 
tion, and nervous derangement, which have long been 
recognized as causative elements in many diseases of 
the skin, often find their ultimate expression or mode 
of action through the faulty metabolism induced 
thereby. 

9. Metabolic errors are exhibited in the excreta from 
the lungs, skin, intestines, and kidneys: and of these 
the urine best affords a satisfactory indication, as it 



DISEASES OF THE SKIN 7 

represents nearly one half of the total excreta, and 
practically all of the nitrogenous and soluble mineral 
substances, together with about one half of the water 
expelled from the system. 

10. Complete and minute volumetric urinary analysis 
is a very great aid in discovering metabolic errors, and 
in establishing proper therapeutic measures for the cure 
of many diseases of the skin. 

We see, then, that there is a thoroughly scientific 
basis for the thesis that diet and hygiene are of im- 
portance in relation to many diseases of the skin, and 
most of us can recall instances where the clinical evi- 
dence of this was irresistible. Thus, it is a matter of 
common observation that acute erythema or urticaria 
may result in some persons from the ingestion of cer- 
tain forms of fish, particularly shell fish; and also oc- 
casionally from strawberries, bananas, mushrooms, etc. 
Some individuals are so constituted that whenever these 
are partaken of, the eruption will appear, while many 
others are thus affected only when the articles are stale. 
It is also well known that in some persons crops of acne 
follow the free use of certain articles, as buckwheat, 
chocolate, nuts, cheese, etc., while the acne lesions aris- 
ing from gross indiscretions in diet, as from partaking 
largely of fruitcake, mince pies, sausages, etc., are of 
daily observation on all sides. The ill effects on the skin 
of alcoholic drinks, including wine and beer, are well 
known, and many a case of cutaneous disease persists as 



8 DIET AND HYGIENE IN 

long as they are indulged in, but yields to previously in- 
effective treatment when these are abandoned. 

In the same manner in which acute eruptions are pro- 
duced by acutely acting dietary causes, so a chronic er- 
ror in diet can and often does induce, or at least keep 
up, a more chronic cutaneous lesion, which of necessity 
will return as often as a conjunction of causes operates 
with sufficient force. A most evident and well-recog- 
nized illustration of this is found in scorbutus, where the 
hemorrhagic tendency in the skin and other organs is 
plainly due to a deficiency in the acid salts found in the 
vegetable portion of the diet, and is rectified when fresh 
vegetables or fruits are supplied. It is also shown in 
the tendency to the development of the tubercle bacillus 
in the lungs and other organs, including the skin, in 
those whose diet is deficient, especially in phosphates and 
fatty matter. The results of errors in diet are often 
seen in psoriasis, where an excessive consumption of 
protein matter, or indulgence in alcoholics, may bring 
on a fresh attack, whereas there may be entire or com- 
parative freedom from the eruption under a strictly 
vegetarian diet, and teetotalism. In addition to the 
acute effects of alcohol on the skin, which have been al- 
luded to, there is much evidence to show that its habitual 
use has much to do with the ulcerative lesions of syph- 
ilis, while its prejudicial effects on many chronic dis- 
eases of the skin is a matter of daily observation. 

Precisely how diet has its influence upon the state of 



DISEASES OF THE SKIN 9 

the skin cannot be accurately stated at present, for 
unfortunately few have made it a matter of great study 
or observation, and very little is found written upon the 
subject in text books or in current literature. But from 
what has preceded, and from what is known of the sub- 
ject, we may conclude that there are four methods by 
means of which this may occur : 

1. There may be a direct irritating action from the 
ingesta upon the stomach and intestines, giving rise to 
reflex cutaneous eruptions, as in the erythema and 
urticaria from shell fish, strawberries, mushrooms, etc. 
These eruptions sometimes vanish very promptly when 
the offending mass is rejected by the stomach or re- 
moved by purgation. 

2. Articles of diet may produce various forms of 
gastric and intestinal indigestion, giving rise to im- 
perfectly elaborated material, or to toxins, which then 
have a direct irritating effect in their circulation through 
the capillaries, and possibly in their attempted elimina- 
tion by the skin; as in acne from indulgence in sweets, 
pastry, cheese, etc., or in psoriasis and some other af- 
fections from an excessive protein diet. 

3. Possibly certain elements may have an action 
directly on the skin tissues, in a manner similar to that 
of some drugs, such as iodides and bromides ; it is more 
than probable that alcohol, which can be excreted by the 
skin, may act in this way. 

4. The error in diet may consist in the absence of 



io DIET AND HYGIENE IN 

certain elements in the diet requisite for the proper and 
exact nutrition of the skin, interfering with the process 
of keratinization, or otherwise; even as rickets arise 
from absence of the proper salts in the food, and scor- 
butus, from the absence of fresh vegetable acids and 
salts, which disorders are checked when these are sup- 
plied. 

Much as has been written concerning diet of late 
years it must be agreed that practically but few, either 
in or out of the profession, have thoroughly clear views 
in regard to the matter of its connection with disease 
of the skin, and fewer still put any great amount of 
thought on the subject, or follow perfectly and per- 
sistently any definite plan or rules of diet and life. 

A healthy appetite and good common sense should 
ordinarily be sufficient guides in the matter of diet, but 
unfortunately one or both of these may be lacking ; more- 
over, the refinements of civilization have added greatly 
to the temptation of overeating, as well as wrong eating 
and drinking, as they do to many other temptations. 
Witness the very common remark, when a tempting 
dessert is offered, "Oh, I have had enough to eat, but 
that looks very good; I will try a little"; and so the 
poor digestive organs are taxed just so much beyond 
their powers. Few persons distinguish between appe- 
tite and taste; they gratify their taste long after the 
appetite is satisfied. Sir Henry Thompson, 2 in his ex- 

2 Thompson. Diet in relation to Age and Activity. London, 1887. 



DISEASES OF THE SKIN II 

cellent little book on "Diet in relation to age and activ- 
ity" remarks, "I have come to the conclusion that a pro- 
portion, amounting at least to more than one half of the 
disease which embitters the middle and latter part of life, 
among the middle and upper classes of the population, is 
due to avoidable errors in diet." And this is certainly 
so in regard to disorders which appear upon the skin. 

To the popular mind dieting represents a starvation 
or famishing process, generally to be continued for but 
a short time, with a view as it were of starving out a 
disease, when it seems to be expected that the disease 
will remain absent. Now there is no question but that 
total abstinence from food, taking only water for a 
while, is of the greatest value in certain acute febrile con- 
ditions, and in certain gastro-intestinal affections, and 
also in certain congestive diseases of the; skin; and it 
will also be seen later that an extremely light, rice, diet 
for some days is often most beneficial in many cutaneous 
troubles. It is a great error, however, to expect any 
such brief dietary effort to have any permanent good ef- 
fect in such rebellious affections as those which com- 
monly occur on the skin. 

In connection with many skin diseases diet has a much 
broader meaning, and signifies such a regulation of the 
quantity and quality of food and drink taken, its mode 
of preparation, and the time and method of its consump- 
tion, as shall conduce to the restoration and maintenance 
of the health of the body, including the skin. 



13 DIET AND HYGIENE IN 

Errors of diet which may constantly be detected by an 
observant physician are far too numerous to mention, 
and time permits us to consider only a few of them now, 
others will be brought out later. I would like, however, 
first to briefly notice some of the points mentioned in 
this definition of diet, which I find of importance in 
practice. 

First, as to the quantity of food. I have already al- 
luded to the tendency to overeat, and that so many 
gratify the taste long after the appetite is satisfied. It 
is now pretty well recognized that those in the well-to-do 
classes eat too much; and this is also often the case 
among those who are relatively poor. Not that the 
system is too well nourished, for that cannot be, but 
very many eat far, far more than the system requires 
in order to maintain a proper physiological equilibrium 
and to accomplish the work necessary to be done, 
whether it be mental or physical. It has constantly 
happened, when I have placed patients on a very re- 
stricted diet, with careful instructions in regard to the 
items to be mentioned later, that they have stated that 
they never felt better or had greater power of work, 
but that they were not consuming one half or one third 
of the amount of food which they formerly took. Un- 
questionably the overloading of the system with material 
which can be only partially digested and assimilated 
has often given rise to intestinal fermentation and to 
many derangements of metabolism which induce and 



DISEASES OF THE SKIN 13 

perpetuate certain skin affections ; it is most often in re- 
gard to sweets and accessories that this error occurs, 
but gross errors are continually happening in regard to 
the excessive use of food and drink of all kinds, as will 
be seen later. Underfeeding or, rather, undernourish- 
ing, can, of course, induce anaemic conditions which may 
in turn influence the skin, but in my experience this is 
so rarely the case that it is hardly to be considered in 
comparison with errors of overfeeding; and I frequently 
find that this latter, forced feeding, has often been 
wrongly advised by physicians in special cases, instead 
of giving proper attention to matters which will promote 
the correct assimilation of smaller and more appropriate 
quantities of food. 

Second, the quality of the food may often have a very 
great influence on certain eruptions, as will be more fully 
developed later. But in all this attention to diet it must 
be remembered that often "what is one man's meat is 
another man's poison," and it frequently astonishes an 
observant person to see what gross errors of diet can 
often be indulged in with apparent impunity. The sub- 
ject of special articles of diet is a very large one, and 
must be deferred until the next lecture, but it must 
never be forgotten that the question which is often asked 
by patients with certain diseases of the skin, "Does it 
make any matter what I eat?" should always be an- 
swered strongly in the affirmative, as I hope to abun- 
dantly show before these lectures are finished. 



14 DIET AND HYGIENE IN 

The mode of preparation, and possible combination of 
food stuffs are also often of great importance, but these 
can be better considered in connection with the several 
articles of diet to be spoken of in a later lecture. 

The time and method of consumption are very im- 
portant matters, which few realize but which are con- 
stantly seen to affect the digestion and metabolism 
greatly, and may frequently be observed to have very 
considerable influence upon certain diseases of the skin. 
Many will recognize that pleasant surroundings and 
agreeable company are great aids to digestion, and one 
often meets with confirmed dyspeptics, or those who 
suffer greatly under the simplest diet, who can go to 
an agreeable banquet and indulge in very many things 
with apparent impunity, which under ordinary circum- 
stances would be quite impossible. But the reverse of 
this is not recognized often enough, namely the ill ef- 
fects which may and constantly do follow various con- 
ditions or circumstances of an adverse nature, some of 
which will be briefly considered later. 

One of the great faults in the habits of the American 
people is undoubtedly haste in everything, and this is 
continually exhibited in the matter of eating, and con- 
sequently in imperfect mastication and inadequate in- 
salivation. It would seem almost unnecessary to re- 
mind you that the process of digestion begins in the 
mouth, and that the saliva should play an important part 
in digestion, as shown so strikingly by the instructive 



DISEASES OF THE SKIN 15 

experiments of Sir William Roberts. 3 But the error 
of rapid eating is so continually occurring and unques- 
tionably is the cause of so much trouble, that it is neces- 
sary to call your special attention to it, because sooner 
or later it will certainly be of importance in some of 
your patients, whether they have disease of the skin or 
other complaints. A little observation will show that 
very many swallow their food with very little chewing, 
washing it down with various liquids, and that the time 
consumed for taking even a large quantity of nutriment 
is sometimes a very few minutes. 

Mr. Horace Fletcher has undoubtedly done a great 
service to humanity by his persistent efforts to influence 
others to follow the plan which has done such wonders 
for his own physical health and well being; and the 
words "Fletcherize," and "Fletcher ism" are a great aid 
to the physician in making patients understand both the 
importance of this part of digestion and the method of 
effecting it properly. I will not take time to present his 
reasons and arguments, nor will I enter largely into the 
details of his procedure, with which many of you are 
no doubt acquainted. I may say, however, that being 
familiar with his books and having heard him speak 
twice, and having taken part in the subsequent discus- 
sion on both occasions, I am thoroughly in accord with 
his views, and believe that I have myself personally 
profited by trying to carry out his method of thorough 

8 Roberts. Lectures on Dietetics and Dyspepsia. London, 1886. 



16 DIET AND HYGIENE IN 

mastication and insalivation; and I know that I have 
rendered inestimable service to very many of my patients 
whom I have induced to adopt the plan, more or less 
completely. I think, however, that relatively few per- 
sons succeed in carrying out his method perfectly, and 
consequently many do not reap the full benefit which can 
come from it, when rightly practiced. 

In brief, as I understand it, Mr. Fletcher's idea is to 
compel the mouth and teeth to perform the part in di- 
gestion which nature intended that they should do, and 
with persistent and protracted mastication to resist the 
inclination to swallow a mouthful as long as it can be 
prevented, and until it is perfectly insalivated. And 
this is accomplished easily if the attention is seriously 
and patiently directed to it; and the result of it is, as a 
rule, that far less food is eaten. Too many, of course, 
gratify the taste when they think that they are satisfy- 
ing the appetite, and as Prof. Chittenden has so clearly 
shown, 4 many if not most persons consume very much 
more food than is at all necessary for the perfect equilib- 
rium and efficiency of the system, under the most dif- 
ferent conditions of work. Sir Michael Foster of Lon- 
don, found that when the Fletcher method was pushed 
to its limits, " complete bodily efficiency was maintained 
for some weeks upon a dietary which had a total energy 
value of less than one half of that usually taken, and 

* Chittenden. Physiological Economy in Nutrition. New York, 1904. 



DISEASES OF THE SKIN 17 

comprised little more than one third of the protein con- 
sumed by the average man. ,, 

When Mr. Fletcher was undergoing the experimental 
study of his physical condition at Yale, where at 50 years 
of age he excelled the College athletes in all tests, his 
food cost but eleven cents per day, under his system of 
Economic Nutrition, aided by his practice of thorough 
insalivation. The recent study of the cost of living by 
a govermental commission has shown that the per capita 
consumption of all kinds of food has increased enor- 
mously in the United States during the last ten years; 
in some foods there has been from 10 to 25 per cent., 
or more, increase, so that it is not so much the high cost 
of living as it is the cost of high living which is at fault 
at the present time. And this high living, or excessive 
consumption of food, is unquestionably affecting diseases 
of the skin badly, as well as those of other organs, as I 
have observed for many years in innumerable cases. 

Pardon my taking so much time on this matter, but 
my experience for over forty years has shown me that 
diet is of such supreme importance in so many of the 
cases which come under my care, that I cannot forbear 
being as emphatic as possible, and I strongly advise you 
to read and carefully consider Mr. Fletcher's remark- 
able series of books, and others on the subject. 5 

* Fletcher. The A. B. Z. of our own Nutrition. New York, 1910. 
Fletcher. The new Glutton or Epicure. New York, 1909. 



18 DIET AND HYGIENE IN 

There are many other items connected with diet which 
contribute towards bad digestion which must be briefly 
mentioned, as close observation shows them often to 
have important relations to certain diseases of the skin. 

Mental influences have long been recognized as hav- 
ing an effect in determining or perpetuating eruptions 
on the skin, and it is believed that this occurs often, if 
not chiefly, through their influence upon the digestion. 
Repeatedly patients with eczema, psoriasis, urticaria, 
acne, etc., will have outbursts of eruption following 
household or other worries, which have produced in- 
digestion of more or less acute character. Any strong 
mental excitement can also arrest or delay digestion, and 
it is well known that after-dinner orators are very apt 
to be troubled with sluggish or disturbed digestion, 
which I have repeatedly seen bring on renewed attacks 
of eczema, especially about the face. 

It is well to remember that numerous experiments 
with animals, especially cats, have shown that the per- 
istaltic movements of the stomach and intestines, as 
watched by means of bismuth and the x-ray, will be ar- 
rested completely when the animal is irritated and in a 
rage, and return to a normal action when the animal 
is again soothed. 

Nervous shock has also been observed to be followed 
by the appearance of certain eruptions, and this prob- 
ably operates also through an arrest of the digestive 
functions, resulting in subsequent fermentation and 



DISEASES OF THE SKIN 19 

auto-intoxication. I have known the shock of a sud- 
denly proposed minor operation to arrest the stomach 
digestion in a perfectly healthy lady, aged about 25, so 
completely that the breakfast, taken at about 7,30 re- 
mained absolutely undigested until vomited, when un- 
der ether, at 3.30 p. m., nothing having entered the 
stomach between these hours. 

Fatigue can also delay and interfere with digestion, 
often in a remarkable manner, as patients will frequently 
testify, and many will date back an increased eruption 
to a time when excessive fatigue caused a meal to be 
very slowly digested; in one case I knew of an evening 
meal taken rather late, and after fatigue, to remain in 
the stomach from Saturday evening until Monday after- 
noon, when it was rejected intact, no other food having 
been taken between because of abdominal distress. 

The question of rest before or after eating is also 
often an important one in the treatment of certain dis- 
eases of the skin which are dependent more or less 
upon the digestion. Active exercise is certainly not 
desirable after eating, as is shown by certain experi- 
ments on a pack of hounds. They were all fed alike, 
and immediately half of the pack were taken on a long, 
quick chase, the other half being left in the kennels. On 
returning some of each lot were killed, and in those 
who had been running the food was found undigested, 
as it had been eaten, while in those which had remained 
quiescent the process of digestion was complete. But 



20 DIET AND HYGIENE IN DISEASES OF THE SKIN 

experience shows that recumbent rest or sleep after 
meals generally affects the human being badly, whereas 
half an hour's nap, beginning one hour before the meal, 
is of the most signal advantage in many diseases of the 
skin, by placing the system in a far better condition for 
digestion. 

Finally, irregular eating, both as to the daily meals 
and also between, has often a great bearing upon cer- 
tain diseases of the skin, and should always be looked 
into, especially in rebellious skin cases; and the great- 
est improvement will often be found, under the same 
measures as used before, when this is rectified. 

While the human system is a marvellous mechanism, 
and the more it is studied the more marvellous it ap- 
pears, and while many seem to have a resisting force 
which can overcome all sorts of obstacles to health, it is 
to be remembered, as stated in the beginning of this 
lecture, that there must be a cause for everything; and 
the cause of many diseases of various organs of the 
body, including the skin, is often found to depend upon 
errors of metabolism, and these again upon avoidable 
errors of diet. And in searching out and rectifying 
these we shall secure the greatest degree of success, with, 
of course, the employment of other proper measures. 
In the succeeding lectures I shall endeavor to enter into 
specific details more fully in connection with certain dis- 
eases of the skin and to make practical application of 
the principles thus far evolved. 



LECTURE II 



LECTURE II 

Nutrition as indicated by repeated volumetric urinary analysis. 
Danger signals from the skin. — Excess of nitrogen in the 
food often at fault. — Vegetarian diet may even have this in 
beans, peas and lentils. — Fish and shell-fish. — Spiced foods. 
— Vinegar. — Nuts. — Sweets. — Fruits. — Dried Fruits. — Tea, 
coffee, cocoa, and chocolate. — Alcohol, influence on the skin. 
— Alcoholic drinks, harmfulness in syphilis and many derma- 
toses. 

Gentlemen : — 

In the previous lecture we considered the general facts 
and principles which establish the great importance of 
diet in many diseases of the skin, and some of the fac- 
tors which contribute to the proper digestion of food 
taken. Special emphasis was laid upon mouth digestion, 
namely mastication and insalivation as practiced and 
advocated so strongly by Mr. Horace Fletcher, to whom 
the world is so much indebted for the introduction of 
what is now known as "Fletcherism." We will now 
take up more in detail some of the special points and 
particular items of diet which are of importance in con- 
nection with our subject, and in another lecture we will 
consider more particularly the diet in certain diseases 
of the skin. 

33 



24 DIET AND HYGIENE IN 

We have already seen that the vitality of the skin and 
its ability to resist various forms of disease depends 
largely upon the condition of systemic metabolism, 
which represents the manner in which nutrition is car- 
ried on. Good and bad nutrition are in a measure rela- 
tive matters, varying in different individuals, and also in 
the same person nutrition may be good at one time and 
bad at another time, even in successive days. We are 
never safe, therefore, in assuming that the nutrition is 
good without due investigation, and the time-honored 
method of examining the tongue and feeling the pulse 
is an expression of the natural desire to ascertain some 
definite information as to the performance of the life 
processes ; and these should never be neglected in many 
of the diseases of the skin. But far more is required in 
order to learn as to the effect of diet, and a searching 
inquiry as to the performance of every function can 
alone enable the physician to fully understand in what 
manner nutrition is carried on; we have already seen 
that repeated and careful volumetric urinary analysis 
affords a most valuable indication of this. 

All know that human nutrition depends upon the inges- 
tion of protein, carbohydrates, fats, mineral salts, and 
water, which, with the inspired oxygen, are combined to 
form the elements of the body, to produce heat, and 
create energy, mental and physical. We all know that 
for perfect nutrition the body requires varying amounts 
of these substances according to age and activity; for 



DISEASES OF THE SKIN 25 

the actively growing system quite other nutritive ele- 
ments are required than for old age, as in the young 
there is a constant need of protein to build up the grow- 
ing body; but we have already seen that in general far 
too much food is taken into the system, with the result 
of impaired function of the digestive and metabolic 
powers, and moreover that this occurs far oftener to 
gratify the taste than to satisfy the appetite. And it 
is for the physician to guard his patients against the 
many errors which unconsciously creep in. It is well 
to remember that many eruptions on the skin are but 
signal Hags of danger, indicating deeper defects, often 
in diet, and that to prescribe simply local treatment alone 
is as irrational as it would be to remove the danger 
signal from an open drawbridge or a deranged rail- 
road switch. 

Mention has been made that excess of protein, in meat 
and other nitrogenous food, is one of the elements which 
is chiefly at fault in connection with certain diseases of 
the skin. It would take us too far from the practical 
aspect of our subject to enter at all fully upon the 
physiological chemistry of protein and the injurious part 
it may play in the human organism, which have been 
so greatly elaborated of late by many observers. 
Chalmers Watson * and others have shown in a most 
remarkable manner, by animal experiments, that an ex- 
cessive meat diet alters very materially the microscopic 

1 Watson, Chalmers. Food and Feeding. New York, 1912. Appendix. 



26 DIET AND HYGIENE IN 

structure of very many organs and portions of the body, 
including the sexual organs, and arrests in a startling 
degree the fecundity of rats. 

Suffice to say that it has been abundantly demon- 
strated on animals and clearly shown by Chittenden 2 in 
regard to human beings, that the hitherto accepted es- 
timate of the amount of protein required, namely about 
118 grams daily for a healthy adult, is far in excess of 
the needs even of very considerable activity, and that 
there is greater well being on one half or even one quar- 
ter that amount; indeed "there are a great many ob- 
servations and some facts which warrant the view that 
the nitrogenous waste products of the body — the prod- 
ucts of protein metabolism — are more or less dangerous 
to the well being of the organism." This will be con- 
sidered more fully when we come to the diet of certain 
diseases, especially psoriasis. 

The carbohydrates and fats, as we all know, Have 
to do largely with the production of heat and the ex- 
penditure of mental and physical force, and aside from 
certain unusable portions, are completely oxidized, and 
pass off as water and carbon dioxide, by the lungs, 
kidneys, and skin; they serve also as sparers of pro- 
teids, which also produce heat in their oxidation. 
Vegetarian products, while consisting mainly of carbo- 
hydates and water, also themselves contain varying 
amounts of vegetable protein, and salts, which in the 

2 Chittenden, Physiological Economy in Nutrition. N. Y., 1904. 



DISEASES OF THE SKIN 27 

herbivora provide quite sufficient nitrogen to build up 
and preserve the animal tissue from which we obtain 
our nitrogenous food. It has been abundantly demon- 
strated both experimentally, and by the thousands who 
have practiced it for years, that an exclusively vege- 
tarian diet can also supply all the protein necessities of 
man, and can keep him in perfect health, and can pre- 
serve a nitrogenous balance, under the most varying 
conditions of existence and activity. It is a well-known 
fact that vegetarians have repeatedly and almost con- 
stantly won in very severe athletic contests, and for 
many years I have observed scores of patients, some of 
them over long periods of time, who have experienced 
so great well being, and such clearness of mind and 
vigor of body, that they have stated that they would not 
for any consideration return to a mixed diet. From 
much study of what has been written on the subject, 
and from observation for many years, I am thoroughly 
convinced that in a not inconsiderable number of dis- 
eases of the skin these troubles are overcome more 
quickly and easily, and permanent results are more 
surely obtained, by adherence to a strictly vegetarian 
diet, than under one with an admixture of animal pro- 
tein, while under much the same local and internal treat- 
ment. 

It must not be forgotten, however, that certain articles 
belonging to the vegetable kingdom contain a very large 
proportion of protein, indeed, some of the pulses, as 



28 DIET AND HYGIENE IN 

dried beans, peas, and lentils, are so rich in nitrogen 
that they have been called "the poor man's beef"; and 
I have found that when they are largely indulged in they 
will have the same effect as does meat, in exciting 
an eruption of psoriasis. Their percentage of protein 
varies from 21 to 32.9 while raw beef has 22.51 
per cent, and roast beef only 34 per cent, of nitrogenous 
matter. It may be interesting to mention in this connec- 
tion the fallacy which has so long existed in regard to 
the superiority of poultry in place of butchers' meat as a 
less nitrogenous diet; for the percentage of protein in 
different species varies from 20.8 per cent, to 25.7 per 
cent., the latter being found in the white meat of the 
turkey. 

Fish is commonly regarded as injurious in diseases 
of the skin, because on certain occasions an acute out- 
break of urticaria has followed its ingestion; but these 
attacks can almost always be traced either to other 
causes, or to some peculiar idiosyncrasy, in the individ- 
ual, or possibly to a stale or bad portion of fish. There 
is no intrinsic reason why fish should not be taken. As 
far as is known there is nothing in good, fresh fish which 
is prejudicial to skin affections ; only it must be remem- 
bered that "protein and fat are the chief nutrient con- 
stituents found in fish, just as they are in meat," 3 and 
that the percentage of protein ranges from 14.2 to 22 

3 Hutchison. Food and the principles of Dietetics. 3rd edition, N. Y., 
191 1. 



DISEASES OF THE SKIN 29 

per cent., almost as high as in some meats. But prac- 
tically fish is often found to take the place of meat with 
advantage, as it is less rich in extractives and so less 
stimulating, and also perhaps, because the actual quan- 
tity or weight eaten is commonly less. Some of the 
heavier varieties, however, such as salmon, blue fish, and 
mackerel, which contain much protein, will sometimes 
so disturb the digestion that an eruption may result; 
but in the main fish seems at times a peculiarly good 
feature of diet to replace meat, when it is desirable to 
curtail the nitrogenous intake. Recent researches tell 
us, however, that fish is not so rich in phosphorus as 
formerly supposed, and that it is not, therefore, pecul- 
iarly valuable as nerve food. Salted fish is not very 
desirable in skin affections, but experience shows that 
when occasionally taken in moderate quantities it does 
no harm. 

There is one disease, however, which is spread by 
eating fish, and that is leprosy, as Mr. Jonathan Hutch- 
inson has so conclusively shown, 4 and as many of us 
have long believed. But this need cause no alarm, for 
it relates only to fish which has been infected with the 
leprosy bacillus, even as infected oysters may communi- 
cate typhoid fever and mosquitos may convey malaria 
or yellow fever, when they have harbored the microbe. 
Thorough cooking destroys the parasite, but in regions 
where leprosy has spread fish has been eaten raw or 

♦Jonathan Hutchinson. On Leprosy and fish eating. London, 1906. 



3 o DIET AND HYGIENE IN 

only dried or lightly smoked or salted; some of the 
sporadic cases of leprosy in this country may have come 
from caviar, which is the uncooked roe of certain fish 
which may come from leprous centers. 

Shell-fish are also of bad repute in connection with 
'diseases of the skin, but aside from their indigestibility 
as they are often prepared for the table, I have never 
been able to see any intrinsic reason why they should 
be harmful in this class of cases, nor many definite in- 
stances of their proving so. 

It is a common direction, often given in connection 
with the treatment of many diseases of the skin, to avoid 
spiced foods, whatever may be indicated thereby. I 
have never been able to discover exactly the reason for 
this, unless it be that such may unduly stimulate the 
appetite, and so lead to overeating. There is nothing 
essentially harmful in the very moderate use of condi- 
ments, indeed by promoting good feeling and improving 
digestion they may often be of service in combating 
certain cutaneous troubles : although I have known pa- 
tients who said that such a trouble as pruritus was 
increased thereby. 

Vinegar is also often interdicted unnecessarily, 
whereas good, genuine, acetous vinegar is often benefi- 
cial, as it aids in softening the hard fibres of meat and 
the cellulose of green vegetables, and I have never seen 
cause to believe that it is harmful in diseases of the 
skin. 



DISEASES OF THE SKIN $1 

There is quite a difference, however, in regard to 
vegetables, although most of them may be eaten with 
impunity by patients afflicted with skin diseases. Men- 
tion has already been made of the pulses, beans, peas, 
and lentils which contain a large percentage of protein; 
the same is also true of nuts, which vary in their pro- 
teid element from chestnuts, with 6.6 per cent., to pea- 
nuts which have 27.9 per cent., sweet almonds having 
24 per cent.; chestnuts have a very large per cent, of 
carbohydrates, 45.2 per cent. But most nuts as ordi- 
narily eaten are not readily digested, although very 
thorough mastication aids materially in this. The ob- 
jection to nuts is that they are often eaten after the 
normal appetite has been fully satisfied, and even after 
the system has been overfed by a sweet dessert; as a 
rule nuts had better be avoided by patients with many 
diseases of the skin. I have repeatedly seen fresh at- 
tacks of acne develop after indulgence in nuts. 

Cheese is also an article of dubious value in many 
affections of the skin, and not infrequently patients will 
realize that an eruption has been aggravated after its 
free use. I know that some have advocated cheese in 
place of meat in those subject to uric acid difficulties, and 
where thus used it may have its value. But too often 
cheese is taken as an accessory, after a hearty meal, and 
only adds to the embarrassment of the digestive organs 
and disturbs metabolism. 

Sweets are also a fertile source of digestive disturb- 



32 DIET AND HYGIENE IN 

ance leading up to trouble on the skin, as patients will 
continually testify. But sugar itself, a practically pure 
carbohydrate, has a high food value, for every gramme 
of it will yield 4.1 calories of energy, and numerous 
experiments have shown that as a muscle food it excels 
almost any other article. It is, therefore, not desirable 
to cut of! its use entirely, in pure form, but, as we shall 
see later, harm comes from its excessive use, and from 
the manner in which it is largely employed, in various 
combinations with many articles ; for thereby substances 
which otherwise might prove harmless, are rendered 
indigestible, as for example in richly preserved fruits. 

Fruits are often thought to be harmless, or even 
beneficial in diseases of the skin, but here also caution 
is often necessary to be exercised. All know that in 
some individuals strawberries, raspberries, and some- 
times other fruit will produce an urticarial eruption 
whenever eaten, and in others only on certain occasions. 
Few of the fruits contain a large amount of nourishment, 
and they are taken more for their sweetness and flavor 
than for their actual food value. But the mineral con- 
stituents of fruits are of considerable importance, and 
consist mainly of potash, combined with various vegeta- 
ble acids, as citric, tartaric, and malic. In some dis- 
eases, as scorbutus these are of important therapeutic 
value, but I have had reason to believe that raw fruits 
as we get them in New York, at all seasons, too often 
ripened artificially, contain too much acid and are not 



DISEASES OF THE SKIN 33 

desirable in many congestive conditions of the skin ; and 
I have certainly seen cases which seemed to be aggra- 
vated by indulgence in them, for instance, especially in 
grape fruit. Fruit stewed without sugar, and baked 
apples are not objectionable, but when made into pre- 
serves they are prejudicial in most skin affections. 

Dried fruits, figs, dates, prunes, and even raisins 
are very nutritious and represent a low protein and high 
carbohydrate contents, which consists mainly of sugar; 
with consequently the very great value of 1615 calories 
per pound in the case of dates. They may, therefore, be 
judiciously employed in connection with a vegetarian 
diet when this is indicated. 

Tea, coffee, cocoa, and chocolate are articles of 
common consumption about which one is continually 
asked in connection with various diseases of the skin, 
and it is not always easy to give a definite and satis- 
factory answer. Tea has been shown by Roberts and 
others to inhibit the conversion of starch into sugar by 
the saliva and also to retard digestion in the stomach, 5 
and there is no doubt but that its excessive use, or 
abuse, produces certain nervous conditions which can 
greatly aggravate certain diseases of the skin. Its ill 
effects are often seen in working people who keep it 
long brewed and drink it many times daily. Often 
nursing mothers drink tea largely, and I have repeatedly 
seen a nursing infant with severe eczema which had long 

8 Roberts. Lectures on Dietetics and Dyspepsia. London, 1886. 



34 DIET AND HYGIENE TN 

resisted intelligent and energetic treatment, get well 
shortly when the mother ceased tea drinking. When 
freshly drawn and taken very weak once daily it is 
probably harmless in most skin affections, but in rebel- 
lious troubles it is always wise to investigate and regu- 
late the matter of tea drinking. 

Coffee acts on the system somewhat differently from 
tea, though it also retards both the salivary and gastric 
digestion, and affects the nervous system, and through 
it the heart. It is to be remembered that caffeine is a 
medicinal agent of no uncertain character; given in 
large dose to the lower animals it produces hurried 
respiration, restlessness, slightly lowered temperature 
followed by marked elevation in the same, tetanic and 
clonic convulsions, progressive paralysis, and finally 
death from paralytic arrest of respiration; it cannot 
therefore be without effect on the nerves and unstriped 
muscles of the skin. Caffeine also in its chemical com- 
position is closely allied to uric acid and is contraindi- 
cated in gouty conditions, with which so many patients 
with certain diseases of the skin are often affected. It 
is well, therefore, in both acute and obstinate cutaneous 
affections to guard against the harm arising from coffee, 
and if used at all it should be in great moderation, and 
as a rule I exclude cafe noir. The recently introduced 
de Kafa, or coffee from which a large part of the caf- 
feine has been removed, seems valuable, and often agrees 
far better than the natural article. 



DISEASES OF THE SKIN 35 

Cocoa has very much less effect on the nervous system 
than either tea or coffee, and also less inhibitory effect 
on the salivary and gastric digestion ; but the large pro- 
portion of fat it contains renders it sometimes difficult 
of digestion; when made with milk it has been found 
to remain in the stomach 2 T / 2 hours. Phillips' digestible 
cocoa seems to answer very well as a beverage, and 
may be allowed in most skin diseases, if made with little 
or no milk. The theobromine of cocoa, though closely 
allied to caffeine, and existing in about the same per 
cent, as the latter in coffee, does not seem to have so 
deleterious an effect on the nervous system, but cocoa 
contains also a very considerable per cent, of nitrog- 
enous matter. 

Chocolate, as found in commerce is simply ground 
cocoa with the addition of sugar, starch, and flavorings, 
and different samples and makes are found to differ 
very greatly in their chemical constituents; thus, the 
nitrogenous matter has been found to vary from 3.9 
per cent, to 18.14 P er cent., the carbohydrates from 26.8 
to 66.8 per cent., and the fats from 21.2 to 47.1 per 
cent. Therefore when advising in regard to its em- 
ployment there is great uncertainty as to its action ac- 
cording to the variety and brand employed, and it is 
difficult now to speak favorably in regard to its use. 
Time and again I have found acne and eczema to be 
aggravated or kindled up afresh by indulgence in choco- 
late, and it had best be prohibited in rebellious skin 



36 DIET AND HYGIENE IN 

affections, both as a beverage and as a food. An in- 
sidious form of intestinal indigestion, resulting in dis- 
turbed sleep and dreams is often directly traceable to 
chocolate, and this can be an efficient cause of urticaria 
and other skin troubles. 

All of these beverages are commonly taken with more 
or less sugar and milk, which are also to be reckoned 
with in relation to diseases on the skin. We have seen 
that sugar variously combined can act prejudicially; 
later we shall see that milk may be harmful in some 
cutaneous conditions, except when taken according to 
a certain definite plan, and it is often necessary to limit 
its use very greatly in the beverages just considered; 
nor can it be taken with impunity as a substitute bever- 
age by many patients with acne, eczema, urticaria, etc. 

Various substances have been offered in place of tea 
and coffee, such as postum, and beverages made from 
parched cereals, most of which are harmless, though if 
served with much sugar and milk they may still affect 
some skin affections unfavorably. 

Alcohol, and the various compounds containing al- 
cohol, even to a very moderate degree, have very decided 
effects upon the skin, and it is an agent to be by no 
means disregarded in connection with dermatoses of 
various kinds. 6 Time does not permit our entering 
here on any full consideration of the physiological or 

6 Bulkley. The influence of alcohol in certain diseases of the skin. 
Medical Record, Feb. 19, 1910. 



DISEASES OF THE SKIN 37 

pathological action of alcohol. It may be stated, how- 
ever, that experimental study has established the fact 
that alcohol certainly has a prejudicial effect on cell life, 
both vegetable and animal, and pathological studies have 
demonstrated degenerative changes in almost all tissues 
of the human body as a result of the action of alcohol, 
even when taken in moderation internally. It is natural, 
therefore, to suppose that the skin suffers with the rest 
of the economy, and clinical experience shows this cer- 
tainly to be the case, often from even moderate use of 
alcoholic drinks, however well diluted. 

There are several ways in which alcohol may have 
an effect upon diseases of the skin; I. By its effect upon 
the nervous system. 2. By its effect upon the circula- 
tion, and 3. By its effect upon metabolism; all of these 
elements have much to do with the production and con- 
tinuance of cutaneous affections. 

All experiments and observations show that by its 
sedative action on the vaso-constrictor center of the 
medulla, alcohol causes a slight paralysis of the nerves 
controlling the capillaries of the skin, and the sense of 
flushing after its use in any quantity is well recognized. 
This dilatation of the cutaneous capillaries leads to a 
greater flow of blood in the surface of the body, and of 
course to a greater congestion of diseased portions, 
which congestion is one of the chief features in many 
dermatoses most difficult to control. 

Although alcohol in small quantities may act as a 



38 DIET AND HYGIENE IN 

food and be quite assimilated when taken in very great 
moderation, its effects upon metabolism are by no means 
favorable in the long run, as has been abundantly dem- 
onstrated experimentally and clinically, and by the dis- 
turbances produced it readily affects many diseases of 
the skin. Even in the matter of infectious diseases, it 
has been shown that animals intoxicated by alcohol are 
more susceptible to bacterial infection or to toxins than 
are normal animals. It has also been demonstrated that 
alcoholism, acute or chronic, lessens the number of leu- 
cocytes, and that the repair of wounds takes place more 
slowly in drinkers, because of the insufficient supply of 
white blood corpuscles at the area undergoing healing. 

Syphilis furnishes one of the most instructive evi- 
dences of the harmfulness of alcohol on the tissues, and 
Fournier speaks of alcohol as the natural born enemy 
of syphilitics. It is rare to find bad, ulcerative syphilis 
in those who have always been teetotalers, whereas some 
of the destructive lesions seen in steady drinkers are 
most pitiable: this is especially true also in regard to 
brain lesions, and late nervous diseases, as locomotor 
ataxia, polyneuritis, paresis, etc. The most important 
direction to those who have acquired syphilis is that they 
shall totally abstain from all alcoholic and fermented 
beverages indefinitely. 

Acne rosacea also demonstrates in a striking degree 
the injurious effect of alcohol on the skin, and all are 
familiar with the red noses and cheeks of habitual drink- 



DISEASES OF THE SKIN 39 

ers. The reason why this permanent disfigurement 
occurs principally on the face is undoubtedly due to the 
paralyzing effect of cold on cutaneous vessels when 
greatly dilated by alcohol ; with this continued excessive 
supply of blood there is often more or less hypertrophy 
of tissue, which may cause an immense enlargement of 
the nose, resulting in rhinophyma. 

But it is not necessary to take alcohol in the form of 
distilled spirits to have its deleterious effects manifested 
in the skin, for clinical observation shows continually that 
even the lightest forms of wine and beer may be followed 
by eruptions which prove rebellious while they are per- 
sisted in, but the same troubles yield when drinking 
habits are changed. Here probably we have also to do 
with the other ingredients of various beverages, salts, 
acids, ethers, extractives, and the many substances 
entering into their makeup. 

Acne is constantly met with in those who indulge 
in moderation in wines and malted liquors, even to a 
moderate degree, and often it is quite impossible to re- 
move the trouble permanently while these are persisted 
in. 

Eczema often exhibits the baneful influence of alco- 
holic drinks, whether distilled or fermented, and pa- 
tients continually recognize this partially, so that when 
it is made clear to them they are quite willing to forego 
drinking in order to be cured. Time and again I have 
seen fresh attacks brought on by indulgence in them, 



40 DIET AND HYGIENE IN DISEASES OF THE SKIN 

and repeatedly I have been unable to cure the disease 
until these have been absolutely abandoned. In one par- 
ticularly obstinate case of eczema of long standing in 
a gentleman, who could not believe that the moderate 
amount of claret which he drank could influence the 
disease, the eruption persisted most unsatisfactorily, but 
when he abandoned the claret, after long holding out, 
the eruption disappeared under the same treatment as 
before. 

Psoriasis illustrates in a striking manner the injuri- 
ous effect of alcohol on the skin, as many careful ob- 
servers have recorded, and I have seen outbursts of the 
eruption following excesses in this direction; and in 
dozens of instances the eruption has been congested, in- 
flamed, and itchy while they were persisted in, and then 
yield wonderfully well when all alcoholic or fermented 
drinks were absolutely excluded. 

Time forbids going further into the subject, but 
enough has been said to show that distilled and fer- 
mented drinks are a far greater factor in connection with 
many troubles on the skin than many have been disposed 
to admit. One cannot, therefore, be too firm in control- 
ling this element of diet in connection with the maladies 
mentioned, and also in many other diseases of the skin. 



LECTURE III 



LECTURE III 

Liquid needed for digestion. — Mineral Springs. — Value of bev- 
erages; harm from cold drinks. — Milk harmful in many 
cutaneous affections, errors in taking. — Correct method of 
taking. — Absorption versus digestion of milk: physiological 
explanation. — "Alkaline tide. 33 — Good and bad cooking of 
food: combinations. — Diet in relation to age and activity, — 
Vegetarianism. 

Gentlemen : — 

In the last lecture we ended with a consideration of 
some of the beverages commonly taken and their effect 
in certain diseases of the skin, and there are a few more 
of them which I wish to consider. 

Water composes somewhere about two thirds of the 
human body, and is constantly given off by the skin, 
kidneys, and lungs to the amount of from four to six 
pints daily. Some of this excreted water, about one 
sixth, is actually formed in the tissues out of hydrogen 
and oxygen, but much is derived from the food con- 
sumed, which consists of fully fifty per cent, water, and 
the balance is drunk alone or in various combinations. 

Water is, as we know, essential to the proper working 
of the animal system, and the sense of thirst is generally 
a proper and sufficient guide as to the amount to be 

43 



44 DIET AND HYGIENE IN 

taken: and the wild or domesticated animals probably 
never suffer from errors in regard to its use, when a 
proper supply is accessible. But with man the tempta- 
tions of modern life lead to innumerable indiscretions 
in regard to the amount, as well as the character, of 
the fluid taken into the system, some of which we have 
already considered in connection with various beverages 
which are often injurious. There remain some others 
to mention in regard to which errors are liable to occur. 

It has been computed that under ordinary circum- 
stances only about 2% pints of liquid (or about 2 
breakfast cups full, and three tumblers full), are actu- 
ally required to be taken daily by the average person, 
in addition to that contained in the food. This may 
vary, of course, under different conditions, mainly when 
the skin is more active from exercise or in very warm 
weather, and we know of the vast quantities of liquid 
which are called for when the kidneys are extremely 
active in diabetes. But the taking of large amounts of 
fluids unnecessarily both throws undue work upon the 
kidneys, causes a higher arterial tension and unnatural 
strain on the heart, and leads to a certain infiltration of 
the tissues tending to obesity, as may often be observed 
in excessive beer drinkers, such as employes in brew- 
eries. All of these conditions may act prejudicially in 
connection with certain diseases of the skin. 

It is true, however, that in some cutaneous affections 
associated with a gouty habit, an increased ingestion of 



DISEASES OF THE SKIN 45 

water for a while, often serves a very desirable end, 
in dissolving and washing out effete nitrogenous matter 
from the tissues, including the skin. It is well also to 
remember that occasionally one meets with anosmia, 
where there is such an absence of thirst that there is 
a viscosity of the blood, shown by great acidity and high 
specific gravity of the urine, which certainly augments 
any skin difficulty, and calls for relief by increasing the 
kidney secretion by means of copious draughts of water, 
and proper diuretics. 

But it is not an indifferent matter in regard to the 
time and method of taking water, and special directions 
are often necessary lest harm be done. All know the ill 
results which frequently accompany the common Ameri- 
can habit of drinking iced water, especially with or near 
the meals, and the catarrhal conditions following it may 
act prejudicially in many skin affections. While mod- 
ern experimentation has developed the fact that water 
is not absorbed in the stomach, but begins almost at 
once to be forced in gushes through the pylorus, practical 
experience has also shown that much water, especially 
iced water, taken while eating delays the digestion, and 
so may disturb metabolism : but hot water escapes from 
the stomach more rapidly than cold. 

It is well, therefore, in many cutaneous conditions, to 
give hot water one hour before the meal, for it has been 
shown that even a pint of water had passed into the 
duodenum within half an hour. A hint in this direction 



46 DIET AND HYGIENE IN 

may be taken from the many mineral springs which are 
found to be of more or less value in certain cutaneous 
affections; these are all or most of them (even including 
Vichy) hot or warm, and are administered a long time 
before eating. On another occasion I may be able to 
present to you a study on the mineral springs which are 
often advised for eruptive troubles, of which I have 
personally visited a very large number, in this country 
and abroad; I may here say, however, that my report 
on them, from what I have seen of their effect in hun- 
dreds of cases, would not be as favorable as some of 
you might expect, from the laudatory notices which are 
issued largely for commercial reasons. 

In trying to satisfy the general craving for liquids, 
commercial enterprise has furnished a large number of 
beverages which are often offered to the public in a very 
tempting manner, but many of which are not without 
their drawbacks. Time does not permit me to even 
mention the numerous concoctions which allure the un- 
wary, many of which cannot be indulged in without more 
or less injury; this latter is true if for no other reason 
than that they are generally taken iced, to say nothing of 
the many ingredients of which nothing is known, but 
which have sometimes been demonstrated to be actually 
poisonous. As a rule I enjoin my patients to shun them 
entirely, including what is commonly known as soda- 
water; indeed it is desirable for those who have a skin 
affection to avoid taking anything between meals, as 



DISEASES OF THE SKIN 47 

also anything which can possibly interfere with perfect 
nutrition. 

There is one fluid of very general consumption, milk, 
which when taken wrongly can act very prejudicially 
in many cutaneous disorders, but which when rightly 
employed can be of such supreme value that I must de- 
vote a little time to it; although I know that many of 
you are already acquainted with and practice the ideas 
which I have advocated for so many years. But as it is 
necessary, in order to obtain perfectly satisfactory results 
that the plan be adhered to absolutely, even to the 
minutest particular, I will restate the details as briefly 
and clearly as possible. I will premise, however, that 
although the practical utility of the plan has been verified 
in hundreds of instances in my own practice, and by 
dozens of physicians who have spoken or written to me 
on the subject, still the exact manner in which it oper- 
ates does not seem to be wholly in accord with some of 
the modern laboratory experiments on digestion. How- 
ever, when clinical experience clearly demonstrates a 
fact, the burden of proof lies with science rather to ex- 
plain how the result is obtained, than to criticise that 
fact theoretically, on the basis of laboratory experience, 
which seldom represents nature exactly; for, after all, 
the cure of our patients is what we seek, and it is only 
unfortunate when the laboratory and clinical medicine 
do not agree. 

It is a common observation that many cannot take milk 



48 DIET AND HYGIENE IN 

in the ordinary way without producing in them a con- 
dition which is known as "biliousness," and for years I 
have noted that certain eruptions were aggravated when 
milk was freely and carelessly indulged in: but, on the 
other hand, I have for years observed, in many hundreds 
of instances, that the same persons could use milk on 
exactly the plan proposed without this result, and with 
only the most inestimable service. 

There must, of course, be some reason why so per- 
fectly prepared a food as milk is not always properly 
assimilated by adults, when in childhood it forms sucH 
a precious element of diet, under almost all circum- 
stances. The explanation is found, I think, in the 
changed character of the digestive and metabolic process 
which pertain to adult life and tissues; of which we as 
yet know very little. We do know, however, that at 
puberty some change occurs in the system, shown in 
many ways, and illustrated dermatologically by the fact 
that ringworm of the scalp often ceases spontaneously 
at this time, and is very rarely manifested in the adult: 
while at that time acne tends to develop. 

Watching for many years the different behavior of 
milk taken under different circumstances, I ventured 
some years ago 1 to offer certain suggestions in regard 
to the direct absorption of milk, without its undergoing 
the ordinary processes of caseation and digestion, and 

1 Bulkley. Proper Employment of Milk in Diseases of Skin, etc. 
Dietetic and Hygienic Gazette, May, 1908. 



DISEASES OF THE SKIN 49 

clinical experience certainly seems to demonstrate that 
this is possible. For, when taken on exactly the plan 
to be indicated its action is quite different from that 
experienced when taken regardless of the same, as hun- 
dreds will testify who have not heretofore been able to 
make use of it. Not only is there an absence of any of 
the former unpleasant feelings, constipation, etc., but 
there is an immediate refreshment and sense of well 
being: moreover, instead of its interfering with the 
appetite for and digestion of the next meal, one hour 
later, there is an increased appetite and improved diges- 
tion; which would not be the case if the milk took two 
hours to leave the stomach, as has been stated by some. 2 
The theory upon which the present plan of taking 
milk is founded rests upon the similarity of milk to chyle 
(formerly called "milk juice"), from which it is hardly 
distinguishable under the microscope. It is to be re- 
membered that chyle is taken up by the lacteals, and 
discharged through the thoracic duct into the subclav- 
ian vein and vena cava, so reaching the lungs for 
oxidation, before encountering the liver. The question 
then arose if the milk, already in a state of perfect emul- 
sion, could not pass directly into the lacteals in the same 
manner in which the elements of the chyle were 
absorbed, without the process of coagulation, caseation, 
and subsequent gastro-intestinal digestion and absorp- 

2 Hutchison. Food and the principles of dietetics. 3d edit, N. Y., 
p. 122. 



50 DIET AND HYGIENE IN 

tion. The problem, therefore, was to administer the 
milk at such a time and in such a manner that it would 
escape the acid and fermentative elements in the stom- 
ach, during the process of digestion, and so avoid being 
curdled before it could be absorbed. 

Physiologically it is well known that the stomach in 
health does not ordinarily secrete gastric juice except 
under the stimulus of food, although Pawlow 3 has 
demonstrated a psychical secretion before the food 
reaches the stomach. We are told that at a varying 
period after the ingestion of nutriment, the time de- 
pending upon the amount and quality of food previously 
taken and the activity of digestion, the organ has 
finished its task, absorption of certain elements has 
already taken place, other portions have been passed on 
to the intestines for further action, and the stomach is 
found empty, awaiting cause for further activity. At 
this time it is said to lose its turgid color, becomes paler 
and quite flaccid, and its surface becomes bathed with 
more or less of an alkaline solution, forming what is 
known as the "alkaline tide." 

This "alkaline tide" occurs at varying periods of time 
after the ingestion of food, dependent upon many cir- 
cumstances: it may begin an hour or so after a very 
small amount of very digestible food, or it may be de- 
layed four, five, or even many more hours after a very 

3 Pawlow. Cited in Howell. A text book of physiology. Phil., 1906, 
p. 689. 



DISEASES OF THE SKIN 51 

heavy or indigestible meal, or with a very weak or 
sluggish digestion. This should constantly be borne in 
mind and accounted for in connection with our subject, 
otherwise mistakes, errors, and harm will surely result. 
It is only when this "alkaline tide" is perfectly secured 
and utilized that the method of giving milk here recom- 
mended can be successfully carried out. 

Remembering then, that the blood is alkaline, the 
chyle alkaline, and normal milk alkaline, and that the 
cavity of the stomach is in an alkaline condition at cer- 
tain times, as well as the intestines, it was believed that 
if the milk could be presented to the absorbents in an 
alkaline state, and at a blood temperature, immediate 
absorption would take place. To accomplish this it 
must, of course, be introduced quite apart from all solid 
food, or any substance which could excite gastric secre- 
tion. Even the least amount of acidity from a preceding 
meal, or anything taken into the stomach, would coagu- 
late some of the milk, and so start the whole process of 
caseation and digestion, and so thereby defeat the de- 
sired purpose of direct absorption. 

The idea, therefore, is to give the milk alone, pure or 
diluted one third with boiling water, at the body tem- 
perature, just after the alkaline tide has set in, or 
during its continuance, and to avoid food or any sub- 
stance which could call forth gastric secretion until 
after its absorption has been fully accomplished. It is 
manifest that this plan is entirely opposed to the com- 



52 DIET AND HYGIENE IN 

mon practice of eating a cracker with the milk, or even 
the addition of an egg, whisky, etc. This I have re- 
peatedly seen done, through ignorance or mistake of 
directions, and have found that it defeated entirely the 
benefit which ordinarily accrues from the exactly right 
procedure. 

I have been thus particular in detailing the supposed 
physiological basis of the plan of taking milk which I 
advocate because, while it may not accord with some 
of the accepted views of gastric and intestinal action, 
there is absolutely no question in regard to the practical 
bearing of the matter, whatever may be the explanation. 
Hundreds of patients who cannot take milk in any other 
way have been following this plan with the greatest 
benefit, dating back now for twenty years and more, 
and dozens of physicians of high standing have adopted 
it as a working theory, and will testify as to the often 
marvellous results obtained. As to the effects which 
I have seen produced in very many patients, or heard 
related, it is difficult to speak without exhibiting too 
much enthusiasm. There is hardly a single fact in 
medicine or feature in therapeutics of which I am more 
confident, or which I utilize with greater certainty and 
satisfaction. 

At the risk of wearying you a little I must dwell for 
a few moments longer on some practical points. As 
may be judged from what has been said, patients some- 
times fail to grasp the exact method in all its details, 



DISEASES OF THE SKIN 53 

and at first trial the results may not be satisfactory. 
It repeatedly happens that the milk is taken too soon 
after a meal, or, even when apparently a long enough 
interval of time has elapsed, it has happened that, owing 
to a sluggish digestion, or to some especially indigesti- 
ble article of food, the milk has come upon the products 
of a former meal, and not during the "alkaline tide," 
Thus, patients will often take the milk at half-past ten 
or eleven in the morning, or three or four o'clock in the 
afternoon, because at that time they experience a faint 
and "gone" feeling, and mistake the uncomfortable sen- 
sation of delayed digestion for hunger. It will, there- 
fore, at times be difficult to be quite sure that the 
stomach has reached the alkaline condition, at which 
time only can the milk be taken with advantage. 

If the digestion is sluggish it may be necessary to 
administer pepsin or other digestives freely and re- 
peatedly, in order to secure an empty stomach early 
enough; occasionally, if there is any doubt as to the 
alkalinity of the stomach it is well to give one or more 
full doses of bicarbonate of soda a while before taking 
the milk, and even to put a little soda into the milk, if 
there is any question as to its alkalinity. 

The temperature of the milk is likewise an element 
of importance. When taken too cold or too hot the 
effort of the stomach to bring it to the proper tempera- 
ture for absorption will often seem to start gastric diges- 
tion, and a sensation of pressure and discomfort will 



54 DIET AND HYGIENE IN 

follow, quite different from the agreeable and restful 
feelings which accompany its proper use. The milk 
should be gently warmed to ioo° F., never boiled, and it 
is often desirable to effect this by the addition of about 
one third of boiling water. Cream should never be 
added, indeed it sometimes happens that too rich milk, 
as from Jersey cows, disagrees, so that dilution with 
boiling water renders it more easily absorbed, as labora- 
tory experiments have also shown. 

Of course this method of vitalizing the system need 
not be confined to patients with diseases of the skin, and 
it has been repeatedly found by many physicians to be 
of the highest value in those debilitated from many 
causes, in cases of so-called nervous prostration, etc. 
In like manner, in treating many patients with what we 
recognize as different cutaneous maladies, our first 
thought must be to put the individual in the best possible 
condition of health; for it must be remembered that in 
most cases we are primarily to treat the patient and 
the cause of the trouble, rather than simply the local 
disease, special medication, internal or local, being used 
only as may be indicated by the particular skin lesions 
present. 

The nutritive value of this method of reinforcing the 
dietary may be better understood when we realize that 
half-a-pint of milk, the amount which should be taken 
as described, contains from 200 to 225 calories. If, 
therefore, this amount be taken one hour before each 



DISEASES OF THE SKIN 55 

meal we have from 600 to 675 calories, or almost one 
quarter of the total daily amount required by the 
system. But the fact is that this is really extra nour- 
ishment, which when rightly taken not only does not 
interfere with the ordinary meals, but frequently in- 
creases the appetite and improves the digestion so 
markedly that it has to be discontinued for fear of over- 
loading the system. But the afternoon dose alone can 
commonly be continued with advantage for a long 
time. 

Therefore in many cases of disease in the skin it is 
necessary to recognize the need of changing the nutri- 
tion of the patient, by removing harmful elements and 
adding those which improve nutrition, and from long 
experience with this most varied and difficult class of 
patients to handle, I am confident that what I have been 
saying about the improper and proper use of milk is of 
vital importance. Eczema, when at all generalized or 
very chronic is often surely a sign of debility of tissue : 
"Acne, especially when severe, is practically of the same 
nature, and is constantly seen to be harmed by the free 
use of milk with food, so that I invariably include the 
matter of the proper use of milk in my dietary direc- 
tions in regard to these cases: the same is true of 
urticaria, and psoriasis may also be harmed or bene- 
fited thereby: even in such a matter as excessive loss 
of hair there is generally a neurotic or nervous fault, 
which can be more or less remedied by the plan advised, 



56 DIET AND HYGIENE IN 

and many a case of severe or malignant syphilis will 
yield far better when the matter in question is properly 
attended to. Many other instances could be cited, such 
as mothers nursing babies with eczema or other com- 
plaints, where a poor breast milk is at the bottom of 
the trouble ; but we must pass on to consider other diet- 
ary matters. 

Few realize sufficiently the important part which 
good and bad cooking play in health and in the genesis 
and continuance of many ills, including some of the 
skin. Time will not allow us to enter this subject at 
all fully, but it is one which should always receive the 
attention of the physician, in obstinate cases at least. 
Repeatedly I have had patients with various eruptions 
who have gone "into the woods" for health, and on 
their return have realized that their complaint had been 
aggravated instead of being benefited by the ever- 
lasting use of the frying pan, with hot cakes, soda 
biscuit, etc. ; and I continually have occasion to caution 
patients living at home in regard to the harm which 
may come from combinations of foodstuffs in their 
preparation for the table. A common illustration of 
mine, to impress on patients the injurious effect of com- 
binations and cooking, on otherwise beneficial food, is 
in connection with oysters. Some raw oysters could 
be eaten, with crackers and butter on them without 
harm ; but when the crackers are crushed to powder and 
the oysters rolled in them, and then the butter melted 



DISEASES OF THE SKIN 57 

and the oysters fried in it, we have in fried oysters a 
combination which may be far from healthy, if largely 
indulged in. I also instance that sulphur, charcoal, 
and saltpetre can each be burned separately in a stove 
without harm, but when these three are combined into 
gunpowder such an attempt would be most disastrous. 
The ingredients of a mince pie or wedding cake are all 
relatively harmless if eaten alone, but when thus com- 
bined, with cooking, the resulting combinations may be 
most prejudicial to health, and to skin lesions. Further 
illustrations will occur to each of you, and I need say 
no more than to urge that you give this matter serious 
attention and be prepared to strongly and clearly direct 
your patients with rebellious skin affections in regard 
to the many errors of diet from cooking which may 
unconsciously creep in, and so interfere with that per- 
fect metabolism which should be secured in order to 
overcome such difficulties. 

Diet in relation to age and activity also does not re- 
ceive the consideration it should from physicians, and 
patients are notoriously careless in regard to it: brief 
allusion has already been made to Sir Henry Thomp- 
son's excellent little book on the subject, which has 
passed through very many editions, and should be 
widely known. In earlier years the healthy appetite 
of a growing child, if properly guided will lead to 
taking food not only for the production of energy but 
also for building up its increased frame. In middle life 



58 DIET AND HYGIENE IN 

we have already seen, in a former lecture, that the 
majority of persons consume more food than is neces- 
sary or proper, and thus disease is often engendered; 
and this danger is still greater with advancing age, 
when there is no need for growth, and when there is 
also less activity. The illustration of the steam engine, 
though threadbare, is always instructive. The loco- 
motive going sixty miles an hour can come to a halt 
and stand at a station an indefinite length of time and 
keep up steam, but even the uneducated fireman knows 
enough to feed the engine quite differently at different 
times, according to the work to be done. And yet how 
little regard is paid by mankind to caring for their far 
more intricate piece of human machinery with which 
each one is intrusted! 

The physician, who knows the animal mechanism, 
must be the guide and instructor of his relatively igno- 
rant and thoughtless patient in this as in many other 
matters of health ; and this is especially true when called 
on to treat troubles on the skin, which as we have 
already seen are frequently but "danger signals" which 
kind nature often gives as a warning of the infraction 
of her laws. Only to-day a patient aged forty-eight, 
whom I first saw with syphilis twenty-two years ago, 
and had not seen for many years, returned on account 
of a troublesome balanitis, which, of course, he sus- 
pected to be syphilitic. He was now a full-blooded 
man, rather short, and weighing over 200 pounds, who 



DISEASES OF THE SKIN, 59 

'drank considerable beer, ate heartily, an3 exercised 
little, if any. On careful inquiry I found that the 
balanitis was increasingly troublesome, and I recog- 
nized at once, as I have many times before, that the 
local trouble was but an expression of increased sys- 
temic disturbance, creating an acid secretion beneath 
the foreskin, whose retention irritated the delicate 
tissues. His pulse was found to be 92 and hard, and his 
blood pressure when recumbent 180: he was in a fair 
way to drop with apoplexy. Now the only "danger 
signal" which he had heeded, and which led him to con- 
sult a doctor, was a very moderate balanitis, and I hold 
that I should have been culpable if I had prescribed 
only a lotion, which would probably check the local 
trouble; for I then would have left him unwarned and 
unprotected by proper dietary, hygienic, and general 
treatment, to rush on to the danger which confronted 
him, and which would have reproduced his balanitis. 
No one questions, theoretically, that the diet has much 
to do with good or bad health, and even with life and 
death, but few give enough serious attention to diet in 
its relation to age and activity. And yet those who, 
have charge of prisons have instinctively reduced the 
diet of prisoners, so that the hardest-working man can 
instantly stop all activity, and even be kept in solitary 
confinement indefinitely, on prison fare and yet remain 
healthy, when he would have serious illness if he were 
fed exactly as he had been eating before his arrest. It 



60 DIET AND HYGIENE IN 

is strange that so few of us learn by observation and 
experience. 

Closely connected with this subject is that of vege- 
tarianism which has been already briefly alluded to. 
Time does not allow of a full consideration of the sub- 
ject, about which so much has been said and written, 
and which has been so widely practiced in many coun- 
tries and under so many different conditions, with un- 
varying good results. Vegetarian diet for health is no 
new proposition, and needs no defense or explanation. 
All are aware that repeatedly vegetarians have far out- 
stripped meat eaters in athletic contests, while the 
reverse is almost unknown. The mass of human kind 
have always subsisted largely or entirely on the prod- 
ucts of the ground, and in animal life all work is done 
on food from the vegetable kingdom. On the other 
hand the consumption of much meat is of relatively 
modern date, with some exceptions, and is particularly 
common in cities, the mass of workers in rural dis- 
tricts subsisting chiefly on vegetarian products. 

As the error of too much protein in the diet has been 
already somewhat discussed in a former lecture, we will 
not dwell further on our subject, for thus far, to my 
knowledge, there have been relatively few observations 
recorded as to the value of a vegetarian diet in diseases 
of the skin, except in regard to the single disease 
psoriasis. Although this matter will be fully considered 
in a later lecture I may here repeat what I wrote a while 



DISEASES OF THE SKIN 6l 

ago 4 in regard to the value of a strictly vegetarian diet 
in this disease, which I have now studied in more than 
two hundred cases for over twenty years. "It may be 
said without equivocation, that the results of this plan 
of treatment, as watched by my several associates in 
years past and by myself, and also by physicians 
in consultation, and by very many most intelligent pa- 
tients in private practice, far exceed anything which had 
been previously secured by the best of treatment at the 
hands often of the best men in the profession. ,, 

In our next lecture we will take up some of the 
even more distinctly practical applications of diet and 
hygiene in diseases of the skin, and their application to 
particular cutaneous maladies. 

*Bulkley. Report on 140 cases of psoriasis in private practice under a 
strictly vegetarian diet. Jour. A. M. A., Aug. 26, 191 1. 



LECTURE IV 



LECTURE IV 

Diet in Eczema. — Acute eczema, tea, coffee, tobacco. — Rice diet 
controlling acute eczema and inflammatory cutaneous affec- 
tions. — Rationale of dietary treatment: duration. — Infantile 
eczema. — Wheat jelly. — Rationale. — Errors in diet of infants 
with eczema. — Health of nursing mothers. — Diet in chronic 
eczema. 

Gentlemen : — 

In the lectures thus far we have dealt mainly with 
the general elements underlying the principles of diet, 
which are applicable to many diseased conditions, in- 
cluding those of the skin. We will now proceed to 
make more specific application of these to some of the 
cutaneous maladies in which their effect is most strik- 
ing. The thought arises, however, if the element of 
diet is so important in the diseases mentioned is it not 
probable that the same is more or less true in regard 
to many more cutaneous affections, if not indeed in 
regard to all, with the exception of a few of purely 
local origin? May it not be that the rebellious char- 
acter and proneness to relapse of many of them may 
depend to a large degree upon faulty nutrition, depend- 
ent upon erroneous diet? 

Eczema must always come first in any consideration 

6s 



66 DIET AND HYGIENE IN 

of diet, not only because of its great relative frequency, 
one third of all cases, but because it more than other 
eruption reflects the totality of the life of the individual, 
and the manner in which the various bodily functions 
are performed. 

Eczema, in its acute as well as in its chronic stages, 
often exhibits in a remarkable manner the effect of 
diet, both adversely and favorably, and attention should 
always be paid to this phase of treatment, more espe- 
cially when the trouble is either very acute or when it 
is very rebellious. Fresh attacks of eruption are con- 
tinually seen to follow gross errors in eating and drink- 
ing; and also when the disease is chronic and rebellious 
careful investigation will almost always discover some 
faults in diet, and when these are corrected the erup- 
tion is seen to yield to appropriate measures, which had 
previously proved ineffective. A striking instance of 
this was cited in an earlier lecture, where the persist- 
ence in the use of claret wine delayed the cure of eczema 
of the hands, which responded well to treatment as 
soon as the wine was stopped. In many a case of 
chronic eczema there will be found a lowered vitality, 
and the disease will yield and remain absent only when 
the vitality is raised by a most carefully regulated diet 
and hygiene. In some cases the use of tobacco, even 
in moderation, will be an efficient cause of the eruption, 
and an excessive consumption of tea and coffee will also 
have the same effect. Time does not permit our enter- 



DISEASES OF THE SKIN 67 

ing very fully into the many errors of diet which should 
be rectified in chronic eczema, but enough has been said 
in previous lectures to show the lines along which in- 
vestigation should be directed and careful instruction 
given. 

Acute eczema, however, often exhibits in a most 
marked and surprising degree the beneficial effects of 
diet, as some of you have witnessed in previous years, 
in the cases which have been demonstrated in the 
clinics. I have shown some cases from the wards of 
the hospital, where there had been no other treatment, 
internal or local, except the strict diet, which I am about 
to describe, and you have seen the almost immediate 
subsidence of the eruption, under this alone. Many of 
you are, therefore, familiar with my rice diet, of which 
I had a remarkable personal experience which I detailed 
some time ago, 1 and one of your number told me the 
other day of a very interesting circumstance concern- 
ing it. He had employed the diet with great success 
in a number of cases of acute inflammatory diseases of 
the skin, and in one instance a patient had also asthma, 
which ceased entirely while under this regime: when- 
ever ordinary living was returned to the asthma re- 
curred but ceased again while the rice diet was taken. 

The rationale of the treatment will explain, I think, 
why the asthma also was held in check by it. For 

1 Bulkley. Personal experience with a very restricted diet (rice) in 
acute inflammatory disease of the skin. Med. Record, Jan. 28, 191 1. 



68 DIET AND HYGIENE IN 

years my urinalyses have shown me that imperfect or 
deficient urinary secretion is connected with many cuta- 
neous affections, and that faulty nitrogenous metab- 
olism appears to be at the bottom of very many of 
them: and asthma frequently presents much the same 
phenomena, and is often closely allied with certain dis- 
eases of the skin. 2 

It occurred to me some years ago that by relieving 
the liver and kidneys, as far as possible, from the intake 
of exogenous protein, that is, by excluding, temporarily 
at least, nitrogenous elements from the diet, the organs 
would be better able to remove effete nitrogenous 
material from the system, and so relieve the irritated 
tissues of their presence. We know that a high acidity 
of the urine represents to a greater or less degree a 
lessened alkalescence of the arterial blood, from which 
it is excreted, and that an excess of uric acid in the 
urine indicates excessive proteid elements in the sys- 
tem. Now careful volumetric analyses have shown me 
repeatedly that after a patient has been under this 
nitrogen-free diet for a while, the urine may even then 
show an excess of uric acid and urea, which must have 
been taken up by the blood from the tissues, for these 
cannot be produced without nitrogenous material: and 
the clinical results of thus freeing the blood and tissues 
from effete and harmful matter is often most striking 

2 Bulkley. Asthma as related to Diseases of the Skin, British Medical 
Journal, Nov. 21, 1885. 



DISEASES OF THE SKIN 69 

in many cases of acute inflammatory skin affections. 
Over six years ago a gentleman aged forty-five, was 
referred to me with an exceedingly severe attack of 
bullous erythema multiforme, of which he had had two 
similar attacks within the previous three years. He 
had been eating heavily and drinking champagne, and 
the attack had begun at four o'clock on the previous 
afternoon, with a few small papules and much itching. 
Within the twenty-four hours it had developed vio- 
lently, and both hands and wrists were the seat of an 
intense inflammation, with great swelling, and covered 
with small and large bullae, more or less hemorrhagic; 
the intensity of the process seemed to increase even 
while the case was being studied. He was in real 
agony from the burning and itching : the pulse was 88, 
hard and throbbing, and the tongue coated. He was 
given a laxative and an alkaline diuretic, and was 
directed to confine his diet exclusively, for a few days, 
to boiled rice, bread, butter, and water. He was seen 
five days later and the change was remarkable: the 
eruption had cooled down at once, and the hands and 
wrists were then about normal, except for the exfolia- 
tion from the bullae, and he had no discomfort. He 
remarked on the striking difference in the course of the 
eruption under this treatment from what he had ex- 
perienced in the two former attacks. The results 
observed in my own person on several occasions have 
been almost as striking. 



70 DIET AND HYGIENE IN 

Since that time I have given exactly the same form 
of dietary treatment to a very considerable number of 
patients with various acute inflammatory eruptions, 
mainly in private practice, with the most gratifying 
effect, so that I can now almost promise that in a very 
short time there shall be the greatest relief: and I 
assure you, gentlemen, that the results which I have 
secured in many of these cases far exceed anything I 
had previously obtained without it. 

It is, however, in acute eczema that this treatment 
is of greatest value, and by means of it the eruption 
can often or even generally be arrested almost at once. 
Commonly it is necessary to continue it only for five 
days, when a more free diet can be gradually returned 
to, but in certain instances, this diet may be resumed 
with advantage several times, and when it is well borne 
it can be continued even for a long time. Some of you 
will remember the young woman in the hospital, whom 
I showed several times at the clinic, who had a pretty 
general subacute eczema with much deforming arthritis 
of the hands, the fingers of which at first were twisted 
sideways and firmly flexed. For three full months she 
took nothing but rice, bread, butter, and water three 
times a day, and with some appropriate local and gen- 
eral treatment, the eruption vanished, and you will 
remember that the day she left the hospital she could 
move the fingers freely; and she remarked before us, 
that she could now play the piano. In another patient 



DISEASES OF THE SKIN 71 

in private practice the same diet was continued for a 
month with the greatest benefit, and another lady, aged 
forty-five, with very general and severe psoriasis, actu- 
ally persisted voluntarily in this diet for five months, 
with one or two slight breaks when visiting; this was 
followed by a most marked improvement to the psori- 
asis, which nearly disappeared, and with the complete 
cessation of her rheumatism, which had been very dis- 
tressing: her weight did not change markedly, it being 
185 when first seen and i?&}i at the last visit, and her 
general health and vigor were surprisingly improved. 

It is understood, from what has been said, that in 
this treatment the patient takes absolutely no other 
nourishment than the four articles mentioned, rice, 
bread, butter, and water, and this for the three meals 
daily. When this diet is first proposed or ordered 
there is always some remonstrance, and many questions 
are asked in regard to other articles of food and drink : 
but experience has taught me that the best results are 
obtained by adhering strictly and absolutely to the arti- 
cles mentioned, certainly for some days; and invariably 
patients have later expressed entire satisfaction with 
the plan and with the effects produced. 

A word may be added in regard to the preparation of 
and mode of eating the rice, for this has much to do 
with the success of the treatment. It should be 
thoroughly cooked, for half an hour or so, with water 
and not with milk, and generally it is better to have it 



72 DIET AND HYGIENE IN 

dried out somewhat, so as to be flaky, by leaving it 
uncovered on the fire, for a while, say for twenty min- 
utes, with light stirring with a fork. In my own case, 
however, I found that sometimes when it was not so 
dried out, but soft and mushy, I relished it equally well 
and it agreed with me perfectly. 

The rice is to be eaten very slowly, and with a fork, 
with abundance of butter on it and a little salt: it is to 
be most thoroughly masticated, in order to secure the 
full action of the saliva: I commonly tell patients that 
they are to spend as much or even more time in taking 
their simple meal, than any of the others do at the table, 
fully half an hour at least. The bread should be at 
least twenty-four hours' old, and taken with plenty of 
butter; it is also to be very well chewed, "fletcherized." 
Water, hot or cold, but not iced, is to be taken freely, 
but apart from actual eating, and not to be used to wash 
down the food in the mouth. 

The rationale of this diet has already been briefly 
alluded to and should be kept constantly in mind. 
While we know less about the metabolism of the carbo- 
hydrates and fats than we do about that of protein food, 
we do know that the waste products of the former are 
carried off largely by the lungs, and that they are 
sparers of protein consumption, also that they diminish 
intestinal putrefaction. In the endeavor to exclude 
nitrogenous matter from the diet rice was selected as 
being the poorest of all cereals in protein and with no 



DISEASES OF THE SKIN 73 

purin bodies. Bread was also chosen as having on 
the average only 6.5 per cent, of protein, about one fifth 
of which escapes absorption; it contains also on an 
average 51.2 per cent, of starch, sugar, and dextrin, and 
some mineral substances. It was directed that the 
bread should be at least twenty-four hours' old, in order 
to avoid the well-known delay of digestion from that 
which is freshly baked. Butter was given freely, both 
on the rice and bread, in order to supply the requisite 
calories; for a quarter of a pound, which might be 
taken in a day, represents a total fuel of 894 calories, 
or nearly one third of the greatest amount required, 
and it has but a trace of protein. Water alone was 
given, freely, several tumblers full daily, as supplying 
all" the needs of the system, without the possible delete- 
rious action of any substances which might be used 
with it. 

It is not claimed that this diet is scientifically the 
very best that could be devised, but practical experience 
with it in very many cases for over six years shows that 
it acts in a remarkably favorable manner in suitable 
cases, and in no instance has the patient seemed to suffer 
from the absence of the ordinary ingredients of mixed 
diet; and although, of course, certain patients have 
remonstrated at the meagre fare, the ultimate results 
as regard the eruption have satisfied them of the wis- 
dom of the sacrifice; and in many instances there has 
been also a surprising improvement in the general well- 



74 DIET AND HYGIENE IN 

being and power for physical and mental work. In 
many instances, with a return or increase of the erup- 
tion from some cause, the patient has voluntarily 
suggested a return to the rice diet, because of the un- 
questioned benefit experienced previously. 

A word may be added in regard to a return to ordi- 
nary food, when the purpose of the restricted rice diet 
has apparently been accomplished. Sometimes if this 
is done too suddenly there may be a relapse, as in my 
own case, where, partly for experimental purposes, I 
returned at once to a full fare at the end of the first five 
days of the rice diet. At the end of about a week the 
itching returned to my hands, and with it the develop- 
ment of vesicles and blebs in the same localities : I then 
resumed the diet of only rice, bread, butter, and water, 
with no other treatment, internal or external, and the 
irritation ceased almost at once, and in three days 
the vesicles and bullae had subsided, and I have had 
the same experience on a third occasion. 3 

My common direction now is that this rice diet shall 
be continued for five days, and that a mixed diet shall 
be returned to rather gradually, a moderate meal being 
taken at noon, and the rice continued morning and 
night. If all goes well, a light breakfast also is given, 

3 Since these lectures were delivered, I had a fourth attack of my acute 
eruption on the hands, July n, 1912, which was again controlled and over- 
come completely by five days of this diet, without internal or local medica- 
tion; and still later two threatened attacks of gout were at once arrested 
and overcome by this means alone, with absolutely no other measures. 



DISEASES OF THE SKIN 75 

some days later, the rice diet being continued for the 
evening meal for yet a while longer ; the breakfast is to 
consist of a cereal, still with butter, and perhaps eggs 
and bacon, with very little weak coffee or tea. I find 
it well in many of these cases to keep the evening meal 
light for a considerable length of time, as the sleep is 
much better and less likely to be disturbed by itching. 

It is understood, of course, that in laying such great 
stress upon a dietary treatment in acute eczema and 
certain other inflammatory affections I do not by any 
means suggest this to the exclusion of other proper 
therapeutic measures, internal and external, which I 
have elsewhere advised, but I only urge it as a most 
valuable adjuvant which will seldom disappoint. 

In connection with this simple dietary in acute eczema 
in adults I want to bring again to your attention a most 
valuable dietetic measure in infantile eczema which I 
devised a good many years ago, 4 and which you have 
often heard me direct mothers how to prepare and ad- 
minister, for many of the infants who have come to the 
clinics with eczema: I refer to what I have called 
"wheat jelly" which I and others have used with the 
greatest satisfaction for many years, and which is in- 
deed an ideal food, far surpassing the many advertised, 
artificial aliments on the market. 

Bread has long been called "the staff of life/* and 
wheat is recognized as by far the most important of 

* Bulkley. Infant feeding, etc. Jour. Med. Assn., Oct. 15, 1887. 



76 DIET AND HYGIENE IN 

cereal foods, containing all that is necessary to nourish 
the human frame, combined in a wonderfully satisfac- 
tory manner. Thus, the whole grain has the following 
analysis, which may vary slightly in different samples 
from various countries: water, 14.5 per cent., nitrog- 
enous matter 11, fat 1 to 2, starch and sugar 69, cellu- 
lose 2.6, and mineral matter 1.7 per cent. 

In ordinary flour, from which our white bread and 
crackers are made, we get only about 70 per cent, of 
the grain, the endosperm or starchy part alone, while 
the gluten and mineral elements are not utilized; so 
that to secure the entire value of wheat we often resort 
to the various preparations of whole wheat, either 
coarsely crushed, ground or cut up, or made into whole 
wheat flour. This is undoubtedly the food which 
nature intended that man should eat, even as the animal 
thrives best on the entire oat kernel, as does the Scotch- 
man and others on oatmeal and crushed oats. 

The desire then was to find some proper means of 
giving to the growing infant the entire wheat, for 
whose developing tissues a considerable proportion of 
protein and mineral matter is needed, which latter are 
so remarkably well provided in the whole wheat kernel, 
combined with carbonaceous matter; it is, of course, 
necessary to present it in a form for easy assimilation, 
and after experimentation the plan of preparing it to 
be mentioned, was finally adopted. It has, of course, 
long been a custom to add some form of cereal food to 



DISEASES OF THE SKIN 77 

the milk, and for the various preparations on the 
market it has been claimed that each one is superior to 
all others, but the experience of all of us has proved 
the fallacy of all or most of these claims: moreover all 
of these preparations are relatively expensive, and this 
is often quite a burden for those in poor or moderate 
circumstances. The one here proposed has the added 
advantage of being extremely cheap. 

For years it has been advised to use barley water in 
connection with cow's milk, as rendering the curd less 
dense, with the supposed slight advantage of an addi- 
tion of the starchy or other elements of the barley. 
But dissatisfaction with the results obtained with this 
in infantile eczema, and the realization that the young 
child did not thereby obtain all the nutritive elements 
required for its health and growth, led me to inquire if 
there was not some way in which the entire wheat 
could be prepared so that all of its nutritive elements 
could be readily assimilated: these include not only the 
starchy matter in the endosperm, but also the vitalized 
phosphates and salts with the protein of the germ, 
together with the mineral substances and protein form- 
ing the outer layers or bran, which, as we have seen, are 
excluded from ordinary flour. This, of course, re- 
quires proper preparation and cooking, without which 
the young system, at least, could not assimilate them: 
hence the details of the preparation about to be de- 
scribed should be followed most accurately. 



78 DIET AND HYGIENE IN 

In order to secure that the whole wheat kernel was 
utilized I have always insisted that crushed wheat or 
rolled wheat should be employed: this was formerly 
easy to be gotten, but of late .my patients have found it 
difficult, some of the finer (and less valuable) prepara- 
tions having largely taken its place. I am informed 
that what is known as Pettijohn answers well in mak- 
ing wheat jelly, but I am afraid that this does not repre- 
sent absolutely all the wheat: possibly shredded wheat 
biscuits might be better, but I insist that the crushed or 
rolled wheat shall be obtained, if at all possible. 

The wheat jelly is prepared in the following manner: 
about one cupful of the crushed wheat is placed in a pint 
or more of cold water, in a china double boiler, and put 
on the fire at three p. m. This is allowed to boil until 
seven o'clock, when it is set aside, covered up, until 
morning. More water is then added, with stirring, 
and it is again boiled from seven or eight until ten 
o'clock, more hot water being added as necessary to 
make a soft mass. This mass is then placed in a very 
fine sieve and is rubbed through it, with the bowl of a 
spoon, until no more will pass through, and the result- 
ing wheat jelly is scraped off for use during the day, it 
being freshly prepared daily. One to three or four 
teaspoonfuls of this is used at each feeding, according 
to the age of the child and the requirements of the case : 
sometimes it proves quite laxative. Prepared in this 
way it makes a soft, pleasant jelly which mixes readily 



DISEASES OF THE SKIN 79 

with the milk and passes through a feeding nipple: in 
some instances it is desirable to give it alone, in a spoon, 
slightly salted, and a little sweetened with sugar of 
milk. 

The rationale of the preparation described is not diffi- 
cult to understand. Soaking first in cold water tends 
to swell the starch grains, when the slow boiling causes 
them to be thoroughly cooked, and at the same time 
more or less extracts the soluble protein and the mineral 
constituents from the germ and from the crushed bran 
coating. It being then left to cool all night there is 
more or less diastasic fermentation, and in the morning 
the mass is jellified and has a sweetish taste. By again 
boiling this in the morning for three hours all this 
process is arrested and a homogeneous jelly is formed, 
already partly digested, and in a form to be readily 
assimilated; when this is rubbed through a sieve we 
have an extract of all the valuable properties of the 
wheat kernel, only the coarse outer bran coating, from 
which the nutriment has been extracted, being left on 
the sieve. 

For many years I have employed this wheat jelly in 
probably hundreds of cases of infants with eczema in 
private practice and largely among the poorer classes, 
and have yet to find any reason for changing my views 
concerning its extreme value; indeed, I know of many 
mothers who are enthusiastic over the benefits evidently 
resulting from it, and have used it as a nutriment for 



80 DIET AND HYGIENE IN 

more than one child. At first it seems rather a tedi- 
ous process, but after a very short time the routine 
becomes easy, and even among the poorer classes I sel- 
dom find any difficulty in having it carried out per- 
fectly. The jelly does not keep well and should always 
be made fresh every day. 

Infantile eczema often exhibits in a most striking 
manner the ill results from errors of feeding, and many 
cases can be cured solely by correction of the same, 
with the slightest amount of local treatment. Too 
frequent feeding is a common cause of harm in infantile 
eczema, if not the sole cause, in some cases. The 
mother will give the breast whenever the child cries, 
or is restless with itching, thereby aggravating the 
existing digestive disorder, and consequently the 
eczema: this should be strenuously resisted, and the 
breast given not oftener than every two hours or more. 
This is especially true in regard to artificial feeding, 
for it has been abundantly shown that cow's milk takes 
still longer to digest, and feedings should not be at 
intervals of less than three hours. It should never be 
forgotten that the infant requires water also occasion- 
ally in the intervals of nursing or feeding. 

Often in breast fed infants with eczema the error 
may be in the quality of the milk, from a faulty diet 
or condition of the mother. Ale, porter, beer, wine, 
tea, and chocolate are often taken in order to increase 
the flow of milk. These are harmful to the nursing 



DISEASES OF THE SKIN 81 

infant and should certainly be interdicted; gruels of 
various kinds may be employed, but the best food from 
which to form milk is milk, drank freely on the prin- 
ciple and method described in the last lecture. The 
mother should also take milk at night every time the 
baby nurses. 

The health of the nursing mother must also be very 
carefully looked into, for constantly dyspepsia, con- 
stipation, or pure debility in her can be the cause of 
eczema in the nursing baby. It must be remembered, 
however, that these or other errors are not always ap- 
parent upon casual observation, but frequently need to 
be sought for and corrected in the nursing mother, if 
satisfactory results are to be looked for in the eczema- 
tous infant. 

After the period of nursing is over great care is 
often necessary in order that the diet of the eczematous 
child be correct. It is to be remembered that servants, 
to whom the care of children is often too largely com- 
mitted, are commonly taken from the plainer walks of 
life and are apt to be totally ignorant of the principles 
of diet, life, and health. Unless the matter is care- 
fully looked into it will frequently be found that even 
children at the breast, or those who are bottle fed, are 
also given articles from the table of adults, and es- 
pecially that they often get a little tea or coffee, of 
which children are universally fond. Even among 
young eczematous patients in the easier walks of life 



82 DIET AND HYGIENE IN 

I have frequently found indulgence in the most im- 
proper mode of living, candy, chocolate, cakes, etc., and 
many most indigestible articles being given more or 
less freely: and I have known very intelligent persons 
to feed their children affected with eczema in a most 
outrageous and inexcusable manner, quite unchecked 
by their former medical adviser. 

It is very difficult to go into further detail in regard 
to the dietetic treatment of older patients with chronic 
eczema, which may often tax the thought and ingenu- 
ity of the physician very greatly, in order to learn just 
where the error of nutrition lies, and to correct it; 
each case, therefore, has to be studied by itself on the 
principles laid down in this and former lectures. 
Eczema is essentially a disease of debility of some kind, 
in most cases, and one must be careful not to overdo 
the matter of food, but to be sure that a correct and 
sufficient number of calories are taken in digestible 
form. I have seen eczema patients who by the succes- 
sive restrictions of different physicians had been re- 
duced to a very low state of vitality; and I have also 
seen many others who have been so stuffed that they 
were wholly unable to properly assimilate the nutritive 
elements required, and the eruption was thereby kept 
excited. 

Each case will therefore have to be studied, as the 
diet naturally will have to vary according to whether 
the patient is gouty, neurotic, or strumous, or whether 



DISEASES OF THE SKIN 83 

there is plethora or anaemia. From what has been 
said in former lectures, however, it may be understood 
that many eczematous patients will oftener do better 
under a more or less complete vegetarian diet than un- 
der one containing much nitrogenous matter. As has 
been already stated, alcohol in any form whatever is 
commonly contraindicated in eczema. 



LECTURE V 



LECTURE V, 

Acne, dietary causations, errors in diet. — Acne juvenilis, less a 
matter of age than of erroneous diet. — Rapid eating, and 
imperfect mastication. — Milk with food harmful. — Acne 
rosacea, harmfulness of alcoholic and fermented drinks. — 
Psoriasis, effect of diet. — Results from vegetarian diet, — 
Error exploded in regard to Passavanfs so-called meat diet, 
— Explanation of basis for vegetarian diet. — Duration of 
the same. — Urticaria, Acute lichen planus, Furunculosis, 
Mycosis fungoides, Epithelioma, Alopecia, Syphilis, as in- 
Huenced by diet. 

Gentlemen : — 

In the last lecture we 'discussed the dietetic treat- 
ment of eczema, which was found to be most impor- 
tant, for the reason, it was remarked, that eczema more 
than any other eruption reflects the totality of the life 
of the individual, and the manner in which the various 
bodily functions are performed. 

Almost the same may be said of acne which, in so 
many cases, seems to depend largely upon internal 
causes, and to be influenced so very greatly by diet, 
whether for bad or good. This matter has been re- 
ferred to in earlier lectures and need not be dwelt upon 
very largely here. But in speaking of the dietetic 

87 



88 DIET AND HYGIENE IN 

treatment of acne, I must remind you that close ob- 
servation will continually note the occurrence of fresh 
outbreaks or separate lesions from many indiscretions 
in diet, which intelligent patients will recognize and 
acknowledge, when closely questioned. Not only will 
this occur after general overeating, but special articles, 
such as sweets, chocolate, pastry, richly fried articles, 
etc., always bring out more or less of a fresh eruption, 
in certain individuals whenever they are indulged in. 
I have patients in whom nuts will invariably produce a 
new crop of acne, and one intelligent man of 30 always 
has a fresh eruption whenever he eats almost any kind 
of fruit. 

Of course, most patients, even those who recognize 
the etiological relation between acne lesions and die- 
tary indulgence will want to be cured of the eruption 
without any restrictions in diet, but this is impossible. 
Much can be done, it is true, by very active local medi- 
cation, and some internal measures will to a certain de- 
gree control the activity of the lesions without much 
attention to diet and hygiene; but the well-known ob- 
stinacy of the eruption and its proneness to recur in 
many cases can only be met by a rigid adherence to the 
dietary principles here laid down. 

Acne is often regarded as a natural accompaniment 
of youth, as is indicated by the name sometimes given 
to one form of it, acne juvenilis. But the large num- 
ber of young persons who escape any great manif es- 



DISEASES OF THE SKIN 89 

tation of acne, and its continuance often even well into 
life, together with the occurrence of the indurated and 
rosaceous varieties in much later years, which latter 
are so frequently traceable very clearly to errors in 
eating and drinking, all lead one to question as to how 
far the ordinary acne of young persons belongs neces- 
sarily to their age; or whether, when occurring at that 
time it is not rather due to dietary errors ; for we know 
that it is just at this period, during adolescence, that 
many are particularly careless in regard to eating and 
drinking, and are most prone to gratify the taste at 
the expense of the health, or regardless of it. 

However this may be, I am constantly discovering 
errors in the diet of these young patients, which when 
corrected are followed by the yielding of an eruption 
which had previously proved resistant to good treat- 
ment at other hands; and again I see cases relapsing 
when, from absence and carelessness, the dietary re- 
strictions have been neglected, which again yield as 
soon as there was a proper control of the diet and 
hygiene. 

One of the commonest errors to find in young peo- 
ple with acne is that of rapid eating and improper 
mastication, and all that was said in an earlier lecture 
in connection with Fletcherism is peculiarly applicable 
in this disease; the habit of bolting the food with little 
chewing, and washing it down with copious draughts 
of liquid, seems to be well-nigh universal, especially in 



9 o DIET AND HYGIENE IN 

the young, and few deny it if closely questioned. Also 
the habit of eating between meals, and then frequently 
very indigestible substances, is very common, as like- 
wise indulgence in soda-water, ice cream, etc. All this 
may seem commonplace and hardly worthy of scien- 
tific notice, but I assure you that wide experience in 
managing large numbers of cases of acne in young per- 
sons, in private practice, has led me to attach very 
much importance to all these simple details. 

Mention has already been made that milk, taken in 
connection with food is harmful in acne, and yet it 
is rare to find acne patients who do not thus indulge in 
it until checked; the idea being so common that they 
require extra nourishment, and that milk is nourish- 
ing, which is true, when it can be properly assimilated. 
While it is a fact that in many young persons acne is 
a sign of debility, it is also true that most commonly the 
debility is due to faulty metabolism, which disturbance 
milk taken with food only increases. On the other hand 
under proper general treatment and when the system 
is in a right condition, milk given alone warm, one 
hour before eating, in the manner detailed in a pre- 
vious lecture often proves of the most signal advantage. 
Iced water, both by provoking gastric catarrh and by 
flushing the face will often keep up or aggravate an 
acne. 

In acne of older persons the effect of diet is often 
shown very strikingly, as they will state or acknowl- 



DISEASES OF THE SKIN 91 

edge, and the trouble cannot be permanently removed 
unless this is attended to. The conditions are very 
much the same as have been already mentioned, with 
certain additions. In some cases the custom of taking 
afternoon tea, with its accompaniments, will suffice to 
keep up the eruption until it is abandoned, and con- 
tinually one may learn that hot or warm drinks will 
cause the face to flush and will increase the difficulty. 
Many patients say that soup always increases the erup- 
tion, especially the richer, cream, bisque, and gravy 
soups, and they will state that they themselves have 
learned to avoid them. 

But it is especially in regard to the use of alcoholic 
drinks, even in moderation, that one sees the injurious 
effects of dietary errors in acne in older years, and 
when this is the case treatment is well-nigh futile while 
the habit is persisted in. One of the worst cases of 
acne rosacea which I have ever seen was in the per- 
son of an importer of Moselle wine, who could hardly 
understand that the moderate use of his supposedly 
pure wine could produce such results; yet so it was, 
and he did not improve until he ceased taking it. 

Also ale, and even the weaker beers frequently pro- 
duce an indurated form of acne, which one can almost 
diagnose as thus induced, while the acne rosacea of 
hard drinkers is well known to all. Many who use 
wine only occasionally will recognize that each in- 
dulgence is followed by an increase of rosaceous acne, 



92 DIET AND HYGIENE IN 

although they may not have self-control enough to re- 
frain until so directed by the physician. 

Acne in its various forms may, therefore, be con- 
sidered to be perhaps the most important disease of the 
skin in which attention should be paid to dietary mat- 
ters; and yet in very few of the cases that I see has 
the matter ever been previously considered and regu- 
lated by those who have had charge of the patient, 
whether general practitioners or those devoting special 
attention to diseases of the skin. 

Psoriasis ', as I have repeatedly shown, 1 exhibits in 
a very marked degree the ill effect of erroneous diet in 
inducing and aggravating the eruption, as also the ben- 
eficial or even curative effect of one directed along cer- 
tain proper lines, about to be detailed. 

Any one who has watched many patients with 
psoriasis in private practice over some years must have 
been impressed with the varying amount and character 
of the eruption present at different periods, and must 
have wondered at the reason; for to casual observation 
these patients appear mostly to be in good health, and 
relapses or exacerbations do not ordinarily seem to be 
connected in a very clear way with any great departure 
from soundness of body. 

There is, of course, no reasonable indication that the 
disease is grossly parasitic, or that these variable con- 

1 Bulkley. Vegetarian diet in psoriasis, etc. Jour. Amer. Med. Assn,, 
Nov. 17, 1906. Feb. 22, 1908. Aug. 26, 191 1. 



DISEASES OF THE SKIN 93 

ditions are due solely to any microbic cause, internal or 
external. Climate and the seasons are often recog- 
nized as affecting the appearance of the eruption, 
which frequently improves markedly and may even 
disappear in the summer, reappearing or getting worse 
in the autumn and winter. 

But, to my thinking, there is an underlying cause of 
the disease which in a measure, at least, explains why 
the eruption should vary so greatly from time to time, 
and should persist so rebelliously in a large majority 
of cases. Mention was made that the eruption is apt 
to improve in summer, and it is known that the dis- 
ease is rare or altogether absent in certain hot cli- 
mates. During an extensive trip through the various 
countries of the Far East, 2 although I visited very 
many hospitals and dispensaries and saw multitudes of 
patients with different maladies, and although I in- 
quired diligently, I found no psoriasis ; and my son, who 
has been a medical missionary in Siam over seven years, 
recently sent me a photograph of the first patient he 
had seen with this eruption, a native ; the disease seems 
to be almost unknown in the warm regions of the East. 

Now I explain this improvement of the eruption in 
summer, and the absence of it in warm climates, not 
so much on account of the higher temperature and the 
freer secretion from the skin, as from the nature of the 

2 Bulkley. Notes on Certain Diseases of the skin observed in the Far 
East. Jour. Cutan. Dis., Jan., 1910. 



94 DIET AND HYGIENE IN 

diet in those districts, and in warm weather. We all 
know that in summer less meat is eaten and more of the 
cereals, succulent vegetables, and fruits; while in the 
warm countries of the East the food of the natives is 
almost entirely vegetarian; in many of them, moreover, 
it consists mainly of rice, which I believe accounts for 
the absence of psoriasis and possibly for the rarity of 
epithelioma and cancer. The natural suggestion from 
such observations would be that it would be well to test 
the matter, in regard to psoriasis at least, and see if a 
vegetarian diet had any effect on the disease; and this 
has been done with very definite conclusions. 

Last year I reported to the American Medical As- 
sociation, 3 my observation on 140 patients with pso- 
riasis seen in private practice, during the previous two 
years, who had been placed on an absolutely vegeta- 
rian diet, and in regard to whom careful notes had been 
preserved at each visit. Of these cases some were of 
too recent a date to afford any satisfactory judgment, 
and there were some patients who were unfaithful to 
treatment, and some who were lost sight of; there 
were, however, 81 who were recorded as strictly faith- 
ful to treatment. There were 32 in whom the erup- 
tion was recorded as gone, and 60 in whom it was 
improved. 

It may be properly asked if the improvement in the 

3 Bulkley. Report on 140 recent cases of psoriasis, etc. Journ. Med. 
Assn., Aug. 26, 191 1. 



DISEASES OF THE SKIN 95 

eruption or its disappearance was not due to some other 
measures employed, internal or external. In the large 
majority of cases there was, of course, use made of any 
and all remedies which could influence the eruption for 
good; but it may be said unqualifiedly that by the ad- 
dition of this dietary treatment the results, as watched 
by my several assistants in years past and myself, also 
by physicians in consultation, and by very many most 
intelligent patients in private practice, far exceed any- 
thing which had been previously secured by the best of 
treatment either by myself or at the hands often of the 
best men in the profession; and many observant pa- 
tients have said to me, "You may quote me as a strik- 
ing instance of the unquestionable value of this dietary 
element of treatment." 

But in order to test the matter still more perfectly 
there have been at least half a dozen patients to whom, 
for a period, the absolutely vegetarian diet has been 
given alone, with no internal or external treatment; 
these were mostly inveterate cases, and some of the 
patients were very skeptic, owing to long years of un- 
successful treatment elsewhere. After having the 
matter fully explained, these patients were glad to make 
the test, and have watched with the greatest interest 
as certain lesions have ceased to scale, then faded, and 
finally disappeared entirely, leaving only a stain, which 
ultimately ceased to exist, under an absolutely strict 
vegetarian diet alone. This has been verified time and 



96 DIET AND HYGIENE IN 

again by my recent office associate, Dr. Bechet, and 
others. 

It is true, however, that there will sometimes be a 
recrudescence of the eruption, to a greater or less ex- 
tent, even while the patient is supposed to be under a 
rigid vegetarian diet; but I have never seen an out- 
break which was nearly as severe or persistent as pre- 
vious ones had been ; the lesions will be small and much 
less pronounced, and the eruption will commonly yield 
more readily to appropriate active treatment, dietary 
and medicinal, than had been the case in times past. 

This recurrence of the eruption may be accounted for 
in several ways, and does not at all weaken the argu- 
ment for a vegetarian diet in psoriasis. 

First, it is always possible that the patient may not 
have adhered to the restricted diet as absolutely as re- 
ported. 

Second, the details of an exactly proper vegetarian 
diet have not been as yet all worked out, and it is quite 
possible that some article of the vegetable kingdom may 
lead to the faulty metabolism which is at the bottom of 
psoriasis ; we saw in a previous lecture that beans, peas, 
and lentils contained a large percentage of protein, and 
I had one very intelligent gentleman who reported that 
he had some lesions whenever he ate largely of them. 

Third, there may be such a wrong action of some of 
the internal organs that even a purely vegetarian diet 
does not secure a perfect blood condition. 



DISEASES OF THE SKIN 97 

Fourth, there may be other causes also at work, as 
yet unrecognized, which favor the eruption. 

Many of these cases have been watched also in an- 
other way, which further proves the value of the vege- 
tarian diet. Repeatedly it has occurred that the patient 
for one reason or another, has broken away from the 
rigid rules given, and on returning to a free meat eat- 
ing has had a recurrence or increase of the eruption. 
Such a one has often returned penitently and has gladly 
resumed the dietetic treatment, with a promise not again 
to fall from grace, and the beneficial results have 
shortly become apparent. 

The question therefore arises as to the length of time 
during which it is necessary to subsist solely on a 
vegetarian diet in order to control the disease. I am 
accustomed to tell my patients that it may be necessary 
to continue this course indefinitely; for, if a faulty 
nitrogenous metabolism and excretion is at the bottom 
of the eruption, as it seems to be, the same conditions 
may recur whenever the intake of proteins exceeds the 
power of the system to handle them. In my analysis 
of the cases of psoriasis referred to I found that 21 
had continued the diet from 6 months to one year, 11 
from one to two years, and a number had taken it 2, 
3, 4, 5, and even up to 10 and 20 years. I would not 
say that all these individuals were perfectly faithful to 
the diet, but a large number of them claimed that they 
had adhered to it, and they and I felt that the results 



98 DIET AND HYGIENE IN 

quite justified the means. I might add that very many 
of them were so well satisfied with their well being, 
and increased ability to work, mentally and physically, 
that they would on no account return to their former 
mode of life, nor even to a moderate mixed diet: many 
patients who have thus become vegetarians have said 
to me that they would not on any account touch animal 
food. 

On a number of occasions when I have presented the 
subject of the vegetarian diet in psoriasis in public, 
some one has always questioned or opposed its value by 
referring to the constantly quoted single report of a 
certain Dr. Passavant, who asserted that psoriasis 
could be cured by an exclusively meat diet. Although 
I have exploded this fallacy elsewhere, 4 I feel that I 
must briefly state the facts again, in order that the 
contention may be set at rest; for the text books all 
refer to this single report published forty-five years ago, 
and leave the inference that the suggestion may be of 
value, whereas it is worse than useless. 

The facts are briefly these. In 1867 Dr. Gustave 
Passavant, of Frankfort, Germany, in an open letter 
to Prof. F. Von Hebra, 5 reported that having suffered 
for twenty-five years from psoriasis he was soon free 
from it after entering on an almost absolute meat diet, 
including soup, pork, fats, cod-liver oil, milk, and bacon, 

4 Bulkley. Jour. Amer. Med. Assn., Aug. 26, 191 1. 
5 Passavant, G. Archiv fur Heilk., 1867, p. 251. 



DISEASES OF THE SKIN 90 

and practically no vegetables or bread; he advised also 
against beer, coffee and tea, and spices. He cited one 
case of squamous eczema also relieved by this treat- 
ment. 

There are a number of points in connection with this 
brief report which quite invalidate any importance 
which might possibly be attached to it. I, Dr. Passa- 
vant does not mention if possibly he used any other 
treatment, internal or external, in connection with the 
diet, which may have accounted for the improvement; 
2, then, he does not state if the improvement in his con- 
dition lasted any length of time, or if he had any re- 
turn of the eruption, either under the diet or without 
it; 3, he does not mention the season of the year when 
he improved, for we know that psoriasis will sometimes 
disappear spontaneously with the changing season; 
and, finally, 4, on analyzing the diet mentioned, it is 
seen not to be a meat diet, as he especially mentions 
pork, fats, cod-liver oil, milk, and bacon; it was, there- 
fore, really a largely non-nitrogenous, fatty diet, as 
these articles contain very little protein substance. He 
mentions one single other case, and that of eczema, 
which was benefited by his regime. So all his talk 
about meat diet benefiting psoriasis rests on one single 
case, and that erroneously interpreted ! 

On the other hand, Professor Hebra, 6 to whom Dr. 
Passavant addressed his open letter, ridiculed the claim 

6 Hebra. Lehrbuch fiir Hautkrankheiten, 1874, I, 352- 



ioo DIET AND HYGIENE IN 

made, some years after its publication, and as far as I 
can find, there is little if any corroboration in literature 
of the correctness of the claim of Passavant, that 
psoriasis can be cured by meat diet. Surely if there 
were any truth in it, some proof would be forthcoming 
in the forty-five years which have elapsed since its pub- 
lication. On the other hand there are abundant, though 
brief, allusions in literature to the injurious effect of 
excessive meat eating in psoriasis. My experience 
dating back, some of it twenty-five and more years, and 
especially the 140 recent cases which have been par- 
ticularly studied recently, shows conclusively that not 
only does a meat diet increase psoriasis, but that an 
absolutely vegetarian diet is of the very greatest bene- 
fit in this disease ; also that in certain cases it is capable 
alone of causing the disappearance of a long standing 
eruption, without the use of any external or internal 
medication whatever. It is sincerely to be hoped, 
therefore, that the senseless reference to the Passavant 
incident will now disappear from our text books and 
literature, as it only leads to confusion and misjudg- 
ment. 

A few words may be added as to the physio- 
pathological basis for a vegetarian diet in psoriasis, and 
some practical points in regard to carrying it out. 

In the first lecture we saw that perverted metabo- 
lism, and hence disordered nutrition, had been shown to 
have very much to do with the production and continu- 



DISEASES OF THE SKIN 101 

ance of a number of diseases, including some of those 
affecting the skin; this may result from an erroneous 
intake of food and drink, or from the faulty disposition 
of their elements by the various organs of the system; 
thus, we know that gout can come from the free use 
of certain wines, and likewise that a deficient excre- 
tion of urea precedes the development of fresh outbursts 
of dermatitis herpetiformis, while an excess of or an 
imperfect caring for saccharine substances, resulting 
in glycosuria, accompanies diabetic xanthoma. 

In the same way a failure of the system to properly 
carry out nitrogenous metabolism, and the presence of 
an excessive amount of protein in the diet and system, 
is found to be associated with psoriasis in such a man- 
ner as to indicate a causal relation between the two. 
This nitrogenous derangement is constantly shown in 
the urine, and the average of a very large number of 
very carefully made volumetric analyses in private 
practice showed deviations from the normal, which were 
of the utmost importance; thus, the average specific 
gravity of all specimens was 1.026, while 1.030 to 
1.040, with no sugar, was not uncommon; the acidity 
was invariably high, often three or more times the 
normal, uric acid and urates abounding, and the urea 
commonly increased, even to double the normal amount, 
or more. 

It is realized, of course, that the relative and abso- 
lute amount of nitrogen in the urine varies directly with 



102 DIET AND HYGIENE IN 

the amount of protein taken as food, which is hydro- 
lyzed during digestion and absorption into simpler 
amido-acids. These amido bodies by further hydrol- 
ysis and oxidation may be converted, so far as their 
nitrogen is concerned, into ammonia compounds, and 
may then be eliminated at once as urea by the liver, with- 
out entering into tissue formation at all. 7 

The purin bodies, uric acid, xanthin, hypoxanthin, 
are the end product, as far as the nitrogen is concerned, 
of the physiological oxidation of the nuclein, and give 
a measure of the extent of metabolism in the cell nuclei 
of the food and of the body. 

The remarkable studies by Chalmers Watson and 
others 8 in regard to the effect of an excessive meat 
diet on growth and reproduction, and on the structure 
of many organs and tissues of the body, are most in- 
teresting and edifying in this connection. Plates are 
given showing the microscopic structure of healthy 
control animals on a normal diet, and of those of the 
same litter when given only meat, and the difference is 
most striking. It may be instructive to quote the state- 
ments in regard to the influence of an excessive meat 
diet on the skin of rats. 

"i. The stratum corneum is less compact, and more 
evidently in detachable layers. 

7 Howell. A text book of Physiology. Phil., 1906, p. 755. 

8 Watson, Chalmers. Food and feeding in health and disease. New 
York, 1 91 2. Appendix, pp. 553-6 15. 



DISEASES OF THE SKIN 103 

"2. The stratum granulosum shows no definite 
changes. 

"3. The stratum Malphighii shows in the normal 
bread-and-milk-fed rats a gradual condensation and 
consequent thinning as age advances; in the meat-fed 
rats the layers remain more or less swollen, the cells 
showing greater vacuolation and lessened staining 
capacity. 

"4. The cutis vera shows a more cellular structure in 
all the meat-fed rats. 

"5. The hair is distinctly less advanced in develop- 
ment in the meat-fed subjects." All of which is not 
without its bearing upon psoriasis. The studies on the 
effect of the meat diet upon the structure and action of 
the kidneys are also most illuminating. 

It is recognized that the kidneys act as a kind of a 
balance wheel, striving to keep the arterial blood which 
circulates freely through them in a state of phys- 
iological, nitrogenous equilibrium. When, therefore, 
in ordinary health, we find the urea and uric acid in 
excess, as also the other solid constituents of the urine 
increased, the kidneys being healthy, it is certain that 
they find a surplus of nitrogenous and other matter 
which the system cannot utilize, whose circulation 
through the blood produces various results in the tis- 
sues, which we call disease; and one of these is 
psoriasis. Why it takes this particular form is rather 



104 DIET AND HYGIENE IN 

beyond our present inquiry, but it is more than probable 
that the individual lesions are the direct result of one 
or more of the micro-organisms found on every skin, 
which take on activity when the skin is thus rendered in 
a suitable condition. 

It is to be remembered, however, that the actual state 
of the urine is not always a true indication of the hyper- 
nitrogenous state of the system, for it is well known 
that at times there may be more or less retention of vari- 
ous substances in the liver and tissues, as for instance in 
connection with the uratic deposits in gout ; and the fail- 
ure of the kidney to excrete a proper amount of nitro- 
genous matter may sometimes be quite as significant 
as when there is an excess of solid matter in the urine. 

A few words may be added in regard to the prac- 
tical working out of the problem of a vegetarian diet, 
for by this latter is understood the absolute restriction 
of the food to the products of the ground, with the com- 
plete exclusion of all else except butter, which is al- 
most a pure hydrocarbon. 

When this diet is first proposed many patients hesi- 
tate, and generally remonstrate, not realizing that in 
fact the food of every one is very largely from the 
vegetable kingdom ; when, however, one has given some 
thought to the subject, and after a little experience, 
it is readily found that there is a vast variety of non- 
nitrogenous articles from which a very comfortable 
menu can be provided; as is evidenced by the many 



DISEASES OF THE SKIN ios 

vegetarian restaurants here, and especially in Eng- 
land, and also by many of the health sanitaria where 
this system of living is practiced ; a dietary will be given 
in the Appendix. The subject of an exclusive vege- 
table diet in psoriasis is too great for us to cover fully, 
and we will only consider for a moment some of the 
exceptions to be made, or articles belonging to the 
vegetable kingdom to be guarded against. 

Mention has already been made of the fact that cer- 
tain articles, such as beans, peas, and lentils, contain a 
large percentage of protein; thus, prepared pea flour 
has 27.98 per cent., and soy bean flour has 39.5 per 
cent, of protein, while roast beef contains only 34.23 
per cent, of nitrogenous matter, and some kinds of flesh 
have as low as 20 per cent., which is exceeded by that 
in all of the pulses mentioned. Nuts also, contain 
much nitrogen, and cannot be taken in any quantity. 

Alcohol in any form, even the lightest beer, is prej- 
udicial in psoriasis and in some instances I have found 
better results when I excluded also coffee, cocoa, and 
chocolate, which contain xanthin, allowing only very 
weak tea, and water in abundance. Milk is not al- 
lowed as a beverage, but may sometimes be taken with 
advantage alone, warm, an hour before eating, on the 
plan already detailed. Cereals are to be eaten slowly 
with a fork, with a little butter and salt, and pastry 
and richly fried articles had better be avoided, al- 
though a little fat bacon may be taken occasionally: 



106 DIET AND HYGIENE IN 

butter is the only non-vegetarian substance which is al- 
lowed, and this may be taken freely. 

In regard to the ultimate results, the question may 
be asked, whether psoriasis is curable under a strictly 
vegetarian diet, with other proper treatment. This 
cannot be answered definitely yet, but from watching 
results for over twenty years I believe it to be possible, 
in a considerable share of cases; although for this it 
may be necessary to continue the diet perfectly for an 
indefinite length of time. 

If diet is of such striking importance in the diseases 
which have been mentioned it stands to reason that it 
must be of significance in other affections of the skin, 
and this I have found to be the case. Time forbids 
our entering fully into the details regarding many of 
them, but brief mention must be made of some in which 
I have seen striking results. 

When speaking in a former lecture of an extremely 
rigid vegetarian diet, which I have called the rice diet, 
I mentioned a case of bullous erythema multiforme for 
which I had first devised it. Since that time I have 
used this for a short period in a number of other similar 
cases, with the most distinct advantage, it seeming to 
arrest almost at once the metabolic disturbance upon 
which the eruption depends, with, of course, other 
proper treatment; the cases, however, certainly yielded 
in a manner quite different from that commonly ob- 
served under the same measures alone. In certain cases 



DISEASES OF THE SKIN 107 

of pemphigus I have also seen it have a most satisfac- 
tory influence, as also in dermatitis herpetiformis: in 
one patient with the latter trouble, who was under or- 
dinary vegetarian diet, there was repeatedly a great 
exaggeration of the itching with the production of 
vesico-bullae whenever any nitrogenous food was 
taken, and the greatest relief was obtained at once when 
the rice diet was taken for a few days, before resum- 
ing the ordinary vegetarian diet. In several cases of 
this latter eruption a strict vegetarian diet, over a very 
considerable period, has proved of the most signal 
benefit. 

Urticaria, when acute, is certainly an eruption which 
demonstrates clearly a dietetic etiology, but unfortu- 
nately in many chronic cases it is by no means easy to 
•direct a diet which will suffice to control the disease. 
In acute cases the absolute withdrawal of all food for 
a while, giving only water, is of great advantage, and 
in some chronic cases the rice diet will be of much 
service in making an impression on the disease, fol- 
lowing it by a vegetarian diet. But with some patients 
the matter of the diet in chronic urticaria is a perplex- 
ing one and the ingenuity of the physician will be taxed 
to the utmost to find and rectify the dietary error : this 
must, of course, be done on the principles discussed in 
the earlier lectures. 

Acute lichen planus, which may be very distressing 
when it is acute and very general, has sometimes ex- 



io8 DIET AND HYGIENE IN 

hibited in a remarkable manner the beneficial effect of 
the rice diet, and later a purely vegetarian diet has aided 
greatly in overcoming the disease. 

Furunculosis, when it is accompanied by glycosuria, 
is, of course, properly subject to dietetic management, 
but even when sugar is not present in the urine it may 
be equally necessary to regulate the diet. In young 
college men especially one frequently sees cases which 
have lasted a long time, with continued or repeated at- 
tacks of boils, where the diet is most outrageous, and 
the process can be wholly checked only by careful 
dietary regulations: these cannot be detailed here, but 
are to be carried out on the principles already de- 
veloped. 

It may seem strange to make the claim, but in one 
instance of well-attested mycosis fungoides in private 
practice, which has now been carefully watched for 
nearly two-and-a-half years, the arrest and almost 
complete disappearance of the lesions has seemed to be 
favored, if not largely affected by the absolutely strict 
vegetarian diet which has been maintained during all 
this time 9 : I am confident also that in certain cases of 
epithelioma the progress of the disease has been in 
a measure checked and the cure favored by the strict, 
generally vegetarian, diet which has been enforced: 

9 Since these lectures were delivered there has been in the Hospital 
another most severe and pronounced case, in which the tumors have 
shrunken in a remarkable manner, and much of the eruption faded, under 
an absolutely strict vegetarian diet. 



DISEASES OF THE SKIN 109 

certain it is that indulgence in alcoholics favors the in- 
crease of the disease, which, when at all extensive will 
become congested and often increase more rapidly un- 
der its influence, and again cool down and improve 
more readily with x-rays, or other treatment, under 
total abstinence. Still more strange it may seem to 
speak to you in regard to the value of a dietary regula- 
tion in ordinary alopecia, but long experience has con- 
vinced me that in many cases this is essential in or- 
der to secure the best results; and I am also confident 
that even unexpected good results can often be ob- 
tained when this is added to a previous proper internal 
and local treatment, which had been previously inef- 
fective. We recognize perfectly that the child grows 
its hair de novo from having proper food, and the 
veterinarian also recognizes defective nutrition in ani- 
mals by changes in, or loss of, hair; and it is assuredly 
so in adult human beings. The hour is too late to de- 
velop this interesting subject fully, and I can only throw 
out the hint that in falling of the hair you should study 
the case carefully, and, in the light of all that has been 
said, improve the nutrition by exactly proper attention 
to the diet, including the proper use of milk and rest, and 
I am sure that the results will sometimes surprise you. 

Finally, even in such a disease as syphilis the matter 
of diet should never be neglected. In an earlier lecture 
I dwelt upon the baneful effect of alcoholics, even the 
mildest and in the slightest amount, in this disease, and 



no DIET AND HYGIENE IN DISEASES OF THE SKIN 

I assure you that in many cases other dietary elements 
will often be of the greatest importance. Overfeeding 
can increase the evil effects of the poison, while un- 
der nutrition can be almost as prejudicial. Remember, 
in treating syphilis, that you are dealing with a human 
organism into which a poison has entered, and the 
proper treatment does not simply consist in introducing 
mercury or iodide of potassium, or both, or even salvar- 
san, until the symptoms yield, but that the system must 
be cared for in every particular, in order that it may 
more readily overcome the poison and not be too seri- 
ously influenced thereby. With this thought I must 
close, begging you to study the syphilitic patient and 
apply good medical common sense in regulating every 
feature of his life, including the diet and hygiene, if 
you would really be of the highest service. 

One single word must be added, merely to mention 
what you probably all realize, that in all that I have 
said about diet in various diseases, I am only speak- 
ing rather strongly in regard to one special side of 
therapeutics. You know that I am a great believer in 
proper treatment, internal and external, and I trust that 
the emphasis that I have placed upon dietetics will not 
lead any of you to have any less confidence in, nor that 
it will cause you in any way to neglect the fullest gen- 
eral and local medication which may be necessary to 
overcome each particular disease of the skin. 



LECTURE VI 



LECTURE VI 

Importance of proper hygiene in diseases of the skin: — Regu- 
larity of life. — Importance of regular and effective action 
of the bowels. — Sleep in relation to diseases of the skin. — 
Rest, exercise, massage, occupation, atmospheric conditions. 
— Clothing, Bathing, Turkish and Russian Baths, Sulphur 
and Mercurial Baths, Sea Bathing, effect on diseases of the 
Skin. — Mineral Springs, errors in regard to, and relative 
uselessness of. — Classified list of Mineral Springs, with in- 
dication for their use. 

Gentlemen : — 

In our lectures thus far we have seen that there are 
other agencies of importance and value in the treat- 
ment of many cutaneous diseases besides the local and 
internal remedies commonly employed, and that diet 
may have the greatest influence for good or bad in con- 
nection with them. We will now consider the part 
which hygiene often plays, in the practice of dermatol- 
ogy. This may be considered under two heads, first, 
as related to the individual, and second as related to 
others. 

First, Hygiene as related to the individual. 

Regularity of Life. Order is one of nature's great- 
est laws, and regularity of life is one of the greatest laws 

"3 



314 DIET AND HYGIENE IN 

of health. While nature moves on with a perfect 
periodicity in day and night, the changing seasons, etc., 
modern civilization has so disturbed life, especially in 
the cities, that irregularity of life seems to be the rule, 
rather than the exception, in many matters; and this 
fact is often of vital importance in connection with many 
diseases of the skin. This statement, at first sight, 
may not seem of great significance, but when we con- 
sider that each and every element that can conduce to 
the health or ill health of the individual may have a 
direct effect on the skin, it is readily seen that this and 
other matters relating to hygiene need to be considered 
in connection with some of its diseases, at least, if the 
best results of treatment are to be expected. I often 
have occasion to remind patients of the perfect regular- 
ity of life demanded of athletes, and even of race horses, 
and also of the carefully ordered life required at West 
Point and Annapolis, for those who are to serve the 
country in the Army and Navy. 

Mention has already been made of the importance 
of regularity in regard to eating, and when this is 
looked into it will often be found that the very great- 
est errors have often long existed, even in those suf- 
fering most severely from some skin affections, which 
may have been rebellious for that very reason. 

Regularity in the action of the bowels is always of 
prime importance in connection with many diseases of 
the skin, and yet careful inquiry will continually dis- 



DISEASES OF THE SKIN 115 

cover the utmost carelessness in regard to this, both 
among the young and old. Undoubtedly the natural 
and normal time for emptying the lower bowel is in 
the morning. After the wear and tear of the day the 
results of catabolism are slowly discharged into the 
intestinal canal, and these, together with the refuse of 
the food, have been moved on through the colon dur- 
ing sleep, and are ready to be discharged in the morn- 
ing. With the entrance of fresh food at breakfast, 
peristaltic action begins throughout the intestine, with 
absorption, and under perfectly normal conditions the 
rectum seeks to void its contents at that time. If this 
is neglected then the inclination is apt to be lost, and 
there may be a delay for any length of time, perhaps 
until evening; or possibly, if the call is again neglected, 
there may be obstipation for some days, solely from 
willful or careless rectal atony. 

The older medical writers laid much greater stress 
upon fecal retention than is common today, but no one 
who has carefully studied patients with chronic ail- 
ments over long periods of time can fail to be struck 
with the evil effects of constipation, or the beneficial 
results from proper and free action of the intestinal 
canal : and this is especially true in regard to many dis- 
eases of the skin. The pale, often greenish, hue of the 
skin in many who might be called chlorotics, with a 
dull, often slightly jaundiced color of the sclerotics, 
the muddy, greasy, acne-studded faces of many young 



u6 DIET AND HYGIENE IN 

men and women, and other wrong conditions of the 
skin, are all frequently due largely, if not wholly, to 
carelessness in regard to emptying the bowels at the 
proper time : and the way in which these often clear up 
under proper treatment and guidance are surprising 
and gratifying. 

The reason of this is not difficult to recognize. We 
all know that absorption of liquids can and does take 
place from the rectum, and that not only can patients 
be long fed and nourished by rectal injections, but that 
they can be anaesthetized and made drunk through the 
rectum. When, therefore, fecal matter is long re- 
tained in the lower bowel there is a certain amount of 
absorption, and stercoremia results, producing the 
conditions already referred to. If the thesis which we 
have maintained throughout these lectures is correct, 
namely, that the character of the fluid circulating 
through the capillaries and lymphatics has much to do 
with the integrity of the tissues of the body, and with 
the skin and many of its diseases, it is easy to see that 
a perfectly regular habit of emptying the bowel daily 
after breakfast may often be an important factor in 
regard to the latter. I make it a point to insist on this 
with my patients, young and old, commonly inquiring 
into the intestinal action at each visit, and administer- 
ing such remedies and giving such instruction as may 
be proper and necessary to secure a morning defecation ; 
these should be continued until a regular, normal habit 



DISEASES OF THE SKIN 117 

is established by personal attention to the matter, with- 
out medication if possible. 

I trust that you will pardon my long discussion of 
this subject, which may seem very trite and stale to 
some of you, but experience has taught me that very 
many patients are constantly neglectful in the matter 
referred to, and that as a rule the physicians who have 
previously seen the cases have not given it proper 
attention. 

Sleep. Regularity in the hours of sleep is very im- 
portant in connection with many patients with cutane- 
ous diseases, and sufficient, refreshing sleep, as we all 
know, is essential to perfect health. This is a matter 
which should always receive careful attention, and one 
which I make a great deal of, even at every visit. 
While many are regular and systematic in their bed 
hours, many more are most irregular and careless, and 
unless this matter is carefully inquired into and sternly 
corrected by the physician, even at frequent intervals, 
errors will creep in which certainly complicate some 
obstinate cases of skin affections. To indicate some of 
the features connected with the relation of sleep to cer- 
tain diseases of the skin, I would like to present the con- 
clusions which I reached in a rather extensive article 
on the subject. 1 

1. Sleep is an exceedingly important factor to con- 

1 Bulkley. Sleep in its relation to diseases of the Skin. Med. Record, 
Nov. 20, 1895. 



n8 DIET AND HYGIENE IN 

sider in connection with many diseases of the skin, dis- 
orders of sleep occurring both as a contributing cause 
and as an effect of the same. 

2. Disorders of sleep occurring in patients with dis- 
eases of the skin may arise from many different condi- 
tions: and the six principal causes may be classed as, 
(a) digestive; (b) toxic; (c) circulatory; (d) nervous 
(direct or reflex) ; (e) psychic and (/) cutaneous. 

3. These causes of disturbances of sleep should be 
searched for and relieved, because of the injury result- 
ing from imperfect sleep, in producing or aggravating 
many diseases of the skin. 

4. In cases where the sleep disturbance is caused by 
the disease of the skin, the effort should be made to get 
relief to the insomnia by proper internal and external 
treatment of the skin affection, before resorting to 
hypnotics : attention to details is often very necessary to 
secure this end. 

5. Preparations of opium may be resorted to when 
the disturbance of sleep is caused by pain connected 
with the skin disease, but these are useless or harmful 
when the wakefulness results from itching. Chloro- 
form or ether are not to be advised for this purpose. 

6. Some of the newer anti-neuralgic and hypnotic 
remedies are often of great service in quieting the gen- 
eral irritation and inducing sleep in skin patients, and 
gelsemium and cannabis indica internally are also 
valuable to control itching. It is often desirable to give 



DISEASES OF THE SKIN 119 

repeated doses at half-hour intervals until the desired 
effect is produced. 

If time and space allowed I could give you abundant 
confirmation of each of the above points and any 
number of illustrative cases where disturbance of sleep 
caused an aggravation of eruptions or even their fresh 
appearance; but we must hasten on to other hygienic 
matters which often have a material bearing on some 
diseases of the skin. 

Rest. In the rush of modern life many do not 
recognize the necessity of sufficient rest of a proper 
sort, and one frequently sees cases of various cutaneous 
affections where nervous or physical exhaustion from 
want of proper rest, aggravates the disease or renders 
it rebellious; often activities are undertaken for so- 
called pleasure, which are wrongly regarded as recrea- 
tion, when real rest would have been a more efficient 
re-creation. 

Rest before the meals is most valuable, and is worth 
much more than rest, or lying down, after meals, which 
often induces a very sluggish state of the system. In 
nervous and exhausted subjects a most valuable method 
is to combine rest for exactly half an hour, beginning 
an hour before meals, with the milk treatment already 
described: and I could give many, many instances 
where the transformation of the patient by this simple 
procedure has been simply marvellous. I am very par- 
ticular to direct the patients to lie down in a dark room, 



120 DIET AND HYGIENE IN 

and to be called in exactly half an hour: in this way a 
short nap is commonly secured, and the patient is then 
up for half an hour, refreshed and ready for the meal. 
This is especially beneficial in the afternoon, just one 
hour before dinner, as it takes off the strain and stress 
of the day, and enables the evening meal to be better 
digested. 

Exercise. The question of exercise in connection 
with many cases of disease of the skin is sometimes a 
difficult one to determine, and harm often arises both 
from excessive and deficient exercise. The aim, of 
course, is to have sufficient physical exertion to ensure 
adequate and proper muscular movement, in order to 
effect the proper interchange of nutritive substances 
and the elimination of waste products. 

But, as mentioned in a former lecture, this depends 
very largely on the quantity and quality of the food 
taken and also on the oxygen inspired. It is quite pos- 
sible, therefore, by means of an exactly proper diet to 
have such an equilibrium of nutrition established that 
good health will be maintained with very little exercise ; 
and long observation and experience have convinced 
me that the matter of exercise is often overdone, and 
that in many instances eruptions on the skin are 
harmed instead of benefited by too violent or prolonged 
exertion. It is a mistake to believe that the tired mer- 
chant, banker, or professional man, or weary school 
teacher can with advantage take a long walk home, or 



DISEASES OF THE SKIN 121 

at once engage in violent exercise, bowling, golf, ten- 
nis, basketball, etc., with benefit; and I could give any 
number of illustrative cases where the cessation of this 
overstrain has been followed by the most happy results 
in regard to many a skin affection. 

On the other hand, too sedentary a life with over- 
eating can and often does lead to a stagnation of the 
vital processes, which contributes to the production or 
continuance of certain cutaneous disorders. This is a 
matter which must be regulated by the physician, for 
each case, on its own merits. 

Massage. This is, of course, but a poor substitute 
for voluntary muscular exercise, and I must confess 
that I rarely order it and have had relatively little ex- 
perience with it; although I have had some patients 
with various skin affections who claim to have been 
benefited thereby. It must be used, however, with cau- 
tion when the skin is diseased, for I have repeatedly 
seen skins which have been greatly irritated by the 
process, when advised by others, and even fresh erup- 
tions thereby developed. 

Occupation. The occupation of a patient may 
often have a great bearing on the eruption present, and 
this should always have the close attention of the care- 
ful physician, in the management of many cutaneous 
conditions. 

Not only may an eruption have been directly caused 
by the occupation, as in the case of eczema in washer- 



122 DIET AND HYGIENE IN 

women, masons, plasterers, and others, also when ir- 
ritating dyes, drugs, minerals, or acids inflame the 
surface, but many occupations act in a more or less indi- 
rect manner in causing or fostering an eruption on the 
skin. It is well, therefore, always to be sure whether 
there is any such etiological element which can be re- 
moved or modified in some manner. The matter of 
direct occupational eruptions need not detain us here, 
other than to mention that their cause should be always 
recognized and removed, as far as possible or necessary. 

The indirect effect of occupation is sometimes seen 
very clearly to occur through the agency of the nerves 
or the circulatory system. It constantly happens that 
an overstrained business or professional person will 
have an eruption which is rebellious while the condi- 
tions last, but which will yield readily with rest and a 
relaxation of the strain: the same is true in regard to 
an exhausted mother or overtaxed school teacher or 
scholar. It may not be necessary to stop all occupation, 
and a little thought and planning can often overcome or 
counteract many of the injurious elements. 

Occupations which affect the circulation may also 
have a very prejudicial effect in certain diseases of the 
skin. One of the worst cases of acne rosacea, com- 
bined with indurated lesions, that I have ever seen was 
in a young woman engaged in a shoe store : she would 
do very well under treatment when away from her oc- 
cupation, but when she resumed her work, requiring 



DISEASES OF THE SKIN 123 

the head to be bowed over, the trouble returned with 
severity. In another instance, in a blacksmith, the heat 
and hanging posture of the head, rendered the same 
trouble practically incurable. In cooks or others about 
the fire it is often very difficult to control acne or an 
erythematous eczema of the face, but a great deal can 
be done by avoiding stooping, and by protecting the 
face from the heat with a palm-leaf fan; also in sewing 
and reading, I direct that the head shall be held upright 
and the face turned from the light. 

Circulatory disturbance from occupation is con- 
stantly seen also in car drivers, washer-women, turners, 
and others who have to stand still for long hours: 
eczema and ulceration of the lower extremities will 
sometimes be extremely rebellious in them, owing to 
the fact that the weakened capillaries and varicose veins 
prevent the proper absorption of effused products. 
Elevating the feet actually higher than the head, when- 
ever possible, and even all night by elevating the foot 
of the bedstead, will help a good deal in the cure; but 
happily with the solid rubber bandage, 2 when properly 
applied and worn rightly, during the day, we can com- 
monly control these hitherto rebellious conditions. 

Atmospheric Conditions. Many patients with vari- 
ous eruptions are not only very sensitive to heat or 
cold, but are also conscious of barometric changes in 

2 Bulkley. On the use of the solid rubber bandage in the treatment of 
Eczema and ulcers of the leg. Archives of Derm., N. Y., July, 1878. 



124 DIET AND HYGIENE IN 

the atmosphere and will predict storms some time be- 
fore they occur. Many skin patients feel chilly with- 
out great cause, and may suffer greatly from the heat, 
especially from too dry furnace heat, with a dry and 
irritable condition of the whole skin: it is often well, 
therefore, to modify the air by pans of water in the 
apartment when these conditions exist. 

Clothing. This is a matter which sometimes may 
be of considerable importance in connection with cer- 
tain eruptions, and should receive the attention of the 
physician. Wool I believe to be the best substance to 
wear next to the skin, and I constantly urge it, even 
though it seems to irritate at first : affected parts should 
be protected and treated, and the rest of the surface 
modified by baths, powders, lotions, or ointments, so 
that it may learn to bear the contact of wool. The 
benefit, especially to persons with gouty or rheumatic 
eruptions, when absolutely pure wool has been sub- 
stituted for silk, cotton, or even linen underwear, is 
often very striking. In some instances, however, linen 
mesh underclothing seems to answer well. 

Overheating often aggravates an eruption, and con- 
stantly one sees babies with eczema so bundled up that 
the itching and irritation are augmented greatly by the 
increased and retained perspiration: especially will 
the scalp be kept sore by warm woolen hoods. On the 
other hand, patients with many diseases of the skin 
should be very careful in regard to the outer clothir^ 






DISEASES OF THE SKIN 125 

and guard against sudden exposure, which often plays 
a not inconsiderable part in calling forth new lesions: 
the sensitiveness of the skin and the prominent part 
which it plays in regulating the heat of the system 
should ever be borne in mind when it is diseased. 

Bathing. Much stress is often laid upon the care 
of the skin and the necessity of keeping the pores open 
by frequent bathing. It is indeed true that the skin 
is a great excretory organ, giving off, mainly by in- 
sensible perspiration, almost as much liquid as the kid- 
neys, and at times even more : the amount can be judged 
on a cold winter day, by comparing the great cloud of 
steam rising from the skin of an overworked and heated 
horse, and the small current of vapor coming from the 
nostrils. A certain, though small amount of solid 
matter is also given off in the sweat, while the total 
amount of material elaborated and discharged by the 
sebaceous glands is very considerable. It is impor- 
tant, therefore, that the surface of the skin be kept in 
a proper condition, although I think that a great deal 
that is said about "keeping the pores open" is unneces- 
sary and irrational: animals do not bathe, and yet the 
skin performs its functions satisfactorily: one con- 
stantly sees a dust-begrimed coal shoveller with sweat 
pouring from the face and the clothing wet with per- 
spiration, and yet he seldom bathes. The truth is that 
sweat comes out with some pressure, and will exude 
from any skin however dirty, unless it is covered with 



126 DIET AND HYGIENE IN 

an impermeable varnish, as when the child died who 
was gilded to represent an angel at the coronation of 
Pope Leo X. 

The tendency of modern times is to the very free use 
of water externally, and while the healthy skin may 
stand it, for a while at least, bathing may readily be 
carried to an injurious extent by patients with most dis- 
eases of the skin. Not to speak of the harm which 
sometimes comes from injudicious bathing in the way 
of disordered circulation and internal congestion, and 
their subsequent ill effect upon the skin, we frequently 
find the cutaneous surface greatly irritated by the ex- 
cessive use of water. Many look upon a disease on the 
skin as particularly loathsome, and seem to think that 
some portion of the trouble can be removed by washing, 
and great harm instead of good often results from such 
irrational thinking and acting. 

Toward the close of his life that acute observer and 
student of diseases of the skin, Professor Hebra, of 
Vienna, wrote very strongly to the effect that the mat- 
ter of bathing was constantly overdone: he stated that 
he saw more eruptions in those who were active bathers 
than in those who neglected the skin in this respect. 
And his clientelle represented a very wide range of 
territory, among the rich and poor. And from long 
observation 3 I am convinced of the truth of his state- 
ments, and quite agree with him. 

3 Bulkley. On the use of water in the treatment of diseases of the skin. 
Chicago Med. Jour, and Examiner, Jan., 1880. 



DISEASES OF THE SKIN 127 

Properly medicated baths, when carefully prescribed, 
are undoubtedly of value in certain diseased conditions 
of the skin, but great care must often be taken in drying 
the surface ; this can be best done by hot towels, in order 
to absorb the moisture without friction; important also 
is the immediate treatment of the skin subsequently, by 
means of proper medicinal applications. 

Turkish and Russian baths are often taken with a 
view of "purifying the blood," and eliminating some 
supposed materies morbi through the skin: the fallacy 
of this need not be dwelt on. As a means of promoting 
the activity of the skin they are occasionally of service, 
but it is questionable if the powerful stimulation of its 
glands to excessive action is not often followed by a 
corresponding reaction which is harmful. Turkish and 
Russian baths may be likened to the action of purga- 
tives on the bowels, which, while occasionally they are 
required and are valuable, are certainly prejudicial if 
abused. I may say that I very rarely have occasion 
to order them, but continually see reason to forbid their 
use, and that I have repeatedly seen them aggravate 
eruptions immensely. 

Sulphur and mercurial baths, as ordinarily employed, 
probably do more harm than good, and I have seen any 
number of patients whose skin trouble has been greatly 
increased by them: indeed at present they are ordered 
very little by those best acquainted with diseases of 
the skin, and I rarely have occasion to prescribe them, 



128 DIET AND HYGIENE IN 

but frequently direct their discontinuance. Possibly in 
a very extensive case of tinea versicolor, or aggravated 
general ringworm of the body, or in an occasional case 
of old scabies, sulphur baths may be of service, but 
other measures act efficiently and they are unnecessary, 
and I have seen much artificial dermatitis excited by 
them, even in these eruptions. Mercurial baths may be 
necessary in certain rare cases of syphilis, where it is 
desired to mercurialize the system rapidly, but I be- 
lieve they are but rarely employed rrow, while for other 
skin affections they are generally unnecessary and often 
harmful. 

Sea bathing is often of considerable value in psoriasis, 
and possibly in old lichen planus, but is certainly irrita- 
ting to any acute eruption, and even chronic eczema and 
acne will often be aggravated by it. But sea air and 
even sea bathing are often beneficial to eczematous sub- 
jects when there is little or no eruption, especially to 
those who have lived at some distance from the ocean. 
As a rule, however, those skin patients who have been 
dwelling on the seaboard receive most benefit from a 
complete change to a mountainous region. 

Mineral Springs. It seems to be the common im- 
pression both among the profession and the laity that 
in some mysterious manner mineral springs are "good 
for diseases of the skin," and so multitudes flock to 
them quite irrespective of the malady which afflicts 
them, or of the quality of the waters: patients are 



DISEASES OF THE SKIN 129 

often allured to them by florid advertisements, for com- 
mercial purposes, or by the advice of some one whose 
friend, or friend's friend, was said to have been 
benefited thereby. I do not know if some of the sup- 
posed value of this hydropathic treatment has not had 
its origin in the famous Biblical case, where Elisha the 
prophet told Naaman the Syrian, who was afflicted 
with leprosy, to bathe in the river Jordan seven times : 
and, when he obeyed "his flesh came again like unto the 
flesh of a little child, and he was clean" ; alas, the day 
of miracles is past! 

Now to be of real service the mineral water should 
be as intelligently prescribed as any other remedy: cer- 
tain springs may perhaps be of value in certain forms 
of disease or in some conditions of the system, while for 
others quite a different mineral water is required. 
Failure to discriminate in this respect has led to in- 
numerable disappointments and fruitless or harmful 
journeys, at vast trouble and expense. To advise or 
permit a patient with a cutaneous affection to visit and 
make use of them indiscriminately, is likely to be as use- 
less, if not as harmful, as to send one to a drug store 
without a prescription : and not one in a hundred of the 
multitudes who wander among these resorts, receives 
the benefit hoped for, or expected from the printed 
statements, which are too often colored by personal 
bias or commercial interest. 

But visits to mineral springs, even if they are sucH 



i 3 o DIET AND HYGIENE IN 

as are suitable to the condition present, are often of 
relatively little value because of the neglect of, or errors 
in, the use of proper dietary, hygienic, and perhaps 
medicinal measures at the same time: too often the pa- 
tient drops all other treatment, and may not even con- 
sult a physician at the springs, but blindly drinks or 
bathes, or both, as inclination or the advice of a friend 
or of some attendant may suggest. At the springs 
abroad there are generally competent physicians, some 
of whom have long been resident and made a study of 
the waters, and treatment is carried on more or less in- 
telligently. But in this country the resident physicians 
are apt to be frequently changed, and speaking gener- 
ally, there is not, as a rule, that careful and intelligent 
use of the waters and other proper measures which are 
necessary to secure the highest benefit therefrom. The 
sea trip, rest from care, change of air, scene, and diet, 
together perhaps with a large expectancy of benefit, all 
contribute to the greater results sometimes obtained 
from such treatment abroad, as compared with the too 
frequently useless or harmful results attending visits 
to the watering places in this country. 

The subject of the value of various mineral springs 
is a large one which cannot be adequately treated at the 
present time. My observations, as you may judge 
from what has been said, have been largely of an ad- 
verse or negative character, and I am convinced that 
the relative value of mineral springs as compared with 



DISEASES OF THE SKIN 131 

competent, careful treatment at home has been very 
greatly overestimated; for it has fallen to my lot to see 
hundreds of patients with various cutaneous affections 
who have visited mineral springs either with no benefit 
or with but temporary gain, or who were even made 
worse thereby: while I have known or heard of really 
very few who have been greatly benefited or ap- 
parently cured by this means. As a result of personal 
visits and sojourn at dozens of the most noted watering 
places in this country and in Europe, I am convinced 
that by far the larger share of the patients with skin 
affections who visited them would do infinitely better 
under proper medical care at home, employing an equal 
quantity of ordinary water in the same way as at the 
springs. When studying this subject some time ago 4 
I came to the conclusion that it was the water itself, 
rather than the mineral ingredients it contained, which 
was of benefit. This confirms in a measure what has 
been said in a previous lecture in regard to the value of 
water in promoting proper metabolism, upon which so 
much depends in treating diseases of the skin. 

There are, moreover, several disadvantages which 
one often observes in connection with the supposed 
value of mineral springs, which it is often difficult to 
overcome, and which should be mentioned. The ex- 
pression is often used of a "cure" at such and such 

* Bulkley. What real value have Natural Mineral Waters in the treat- 
ment of diseases of the skin. Medical Record, Jan. 4, 1890. 



132 DIET AND HYGIENE IN 

places (which is really a corruption of the French 
"Cours," and the German "Kur," which mean only a 
"course" of treatment), and patients too often regard 
such a "course" as a veritable cure: so, after being per- 
haps somewhat benefited thereby they will neglect all 
proper treatment and so relapse into their former con- 
dition, or worse. This is peculiarly true in regard to 
syphilis, and for this reason it is questionable if more 
ultimate harm than good has not been done through 
the existence and employment of certain springs which 
have a reputation for the cure of this disease. It is 
now pretty well granted by all that it is really the ener- 
getic treatment with mercury and iodide of potassium 
given at these places which is responsible for any bene- 
fits observed; and it is equally well known that it is 
only by prolonged proper treatment with those same 
remedies that final good results can be obtained: this 
is often neglected after a supposed relatively brief 
"cure" at these places, and I have seen some sad cases 
as a result. 

Another disadvantage is that having tried one or 
more mineral springs without satisfactory results, 
many patients with diseases of the skin become hopeless 
in regard to their condition, and too often fail to secure 
and persist in the proper course of other treatment 
which would be quite able to cure, if persisted in. 

Inasmuch, however, as some of your patients may 
insist on visiting a mineral spring, it may be interesting 



DISEASES OF THE SKIN 133 

and valuable for me to give you some definite informa- 
tion in regard to the character and qualities of certain 
of those which are best known; for the total number of 
those which have been at times vaunted before the pub- 
lic is legion. 

We will find that they are often divided into five 
classes, as follows: I, Laxative; 2, Diuretic; 3, Dia- 
phoretic; 4, Tonic; and 5, Alterative. But they are 
usually classed under their chief ingredients, and we 
will therefore divide them thus, with brief mention of 
their principal uses. We find, therefore, that there are 
eight different classes of mineral waters, as follows: 
1, Pure or indifferent Waters; 2, Alkaline Waters; 3, 
Saline Waters; 4, Sulphur Waters; 5, Ferruginous 
Waters; 6, Arsenical Waters; 7, Bromo-Iodine Waters; 
8, Thermal Waters. 

1. Pure or Indifferent Waters. These often 
serve a good purpose in simply washing out the system, 
and patients will often take them faithfully when they 
will not use ordinary water freely enough: they thus 
lead to the introduction of a sufficient, or surplus quan- 
tity of water, which, as has been remarked, is the main 
element of value in most of the spas visited, whatever 
be the nature of their mineral ingredients. Such are 
the Poland waters of Maine, the Bethesda and Wau- 
kesha of Wisconsin, Blue Ridge of Virginia, and Di- 
vonne, Wildbad, Gastein and others abroad. They are 
of service especially when the urine is of a high specific 



134 DIET AND HYGIENE IN 

gravity and acidity: Bethesda water, bottled (but not 
aerated) is of great value in increasing the quantity of 
urine. 

2. Alkaline Waters. A large variety of these 
are found here and abroad, and occasionally are useful 
in eruptions exhibiting lithsemic and gouty symptoms; 
by their antacid action they are also often of service in 
many conditions. Such are the Vichy at Saratoga, 
Berkshire Soda in Massachusetts, Capon in Virginia, 
and Vichy and Contrexeville, in France, also Vals, 
Baden Baden, Teplitz and others abroad. To this 
class belong likewise the various so-called lithia waters, 
whose value in diseases of the skin, however, has been 
greatly overestimated. They are milder in action than 
those in the next class, and are generally very little 
laxative. 

3. Saline Waters. Many of this class of waters 
contain much of the alkaline element, while in others 
the sulphates of sodium and magnesium preponderate, 
giving rise to the name "bitter waters," which are laxa- 
tive or purgative. To the former belong many of the 
Saratoga Waters, Congress, High Rock, Empire, also 
St. Catherine in Canada, Carlsbad, Wiessbaden, Royat, 
and many others in Europe. Among the latter, or 
more purgative waters may be also mentioned the Crab 
Orchard of Kentucky; Bedford of Pennsylvania, and 
Hathorn of Saratoga, all of which are, however, rela- 
tively mild compared with the Rubinat, Villacabras, 



DISEASES OF THE SKIN 135 

Pullna, Hunyadi, and others abroad. Most of these 
are bottled and are not used for bathing. Between 
these two stand a large class of milder saline waters 
much used for both drinking and bathing, represented 
by Leamington and Malvern in England, and Ems, 
Kissingen, Homburg, and Nauheim, in Germany. All 
these waters are at times of value internally in suitable 
cases, to relieve abdominal plethora and counteract in- 
testinal fermentation, but when used externally they 
may prove irritating to diseased skin. 

4. Sulphur Waters. This class of waters are per- 
haps those which are most sought after by patients with 
diseases of the skin, from the popular impression that 
in some way sulphur is good for this class of affections : 
but I am safe in saying that even this class of waters are 
seldom advised by those well acquainted with this 
branch. As alterative and anti-rheumatic agents they 
may serve a good purpose in certain chronic eruptions, 
but in conditions which are all acute they frequently 
prove harmful. Psoriasis is sometimes benefited by 
their prolonged use, but they are incapable of really 
curing the disease, as may be judged from what has 
preceded. Among those best known in this country 
are Richfield and Sharon in New York, Alburg and 
Highgate in Vermont, Greenbrier White Sulphur in 
West Virginia, French Lick in Indiana, Upper and 
Lower Blue Lick in Kentucky, and Glenwood Springs 
in Colorado: abroad, Harrogate, Aix-les-Bains, Aix- 



136 DIET AND HYGIENE IN 

la-Chapelle, Uriage, Ischl, Loueche-les-Bains, and 
many others are frequented. In the latter place pa- 
tients remain for hours in a large tank together, read- 
ing, playing chess, etc., and at Glenwood Springs, 
Colorado, there is a very large pool, out of doors, in 
which many bathe in the warm sulphur water, even in 
the winter. 

5. Ferruginous Waters. Iron is contained in 
many of the mineral springs here and abroad, which 
are classed as other waters, and this element often con- 
tributes somewhat to the possible benefit sometimes 
obtained from them. There are some springs, how- 
ever, that are distinctly ferruginous, and it is often wise 
to have patients make a stay at one of them for a few 
weeks after a visit at one of the saline or purgative 
waters. Such are the Chalybeate at Sharon, New York, 
the Sweet Chalybeate and Rawley in Virginia, Pyrmont 
and Plombieres in France, Schwalbach in Germany, 
Eisenbach and Franzenbad in Austria, St. Moritz and 
Tarasp in Switzerland, Spa in Belgium, and Bath and 
Tunbridge Wells in England. Most of these waters are 
cold and used only for drinking, and those in Switzer- 
land are frequented mostly for the invigorating air. 

6. Arsenical Waters. There are few if any noted 
arsenical springs in this country. Those best known 
abroad are Levico in Austria, said to be the strongest 
known, La Bourboule, Royat, and Bains-les-Bains, in 
France, Gerace in Italy, and Neunahr in Germany. 



DISEASES OF THE SKIN 137 

While patients with certain diseases of the skin are bene- 
fited by arsenic used in proper doses, in connection or 
combination with other remedies, it is idle to suppose 
that a short stay at any of these places can be effective 
to any great degree: they are, of course, not indicated 
in acute conditions, but occasionally those who have been 
at the alkaline or saline springs receive a certain 
amount of good by a sojourn as long as possible at one 
of these places, as most of the waters also contain a 
certain amount of iron. 

7. Bromo-iodine Waters. In strumous or old 
syphilitic cases some of the springs containing a small 
amount of bromine and iodine are of service. The prin- 
cipal ones are Woodhall in England, Kreuznach in 
Germany, Baassen in Hungary, and Bex in Switzerland. 

8. Thermal Waters. While many of the springs 
already mentioned are hot, some of them very hot, the 
term thermal waters is usually given to those which are 
indifferent, or without any very active medicinal in- 
gredients. Such are Buxton in England, Aix-les-Bains 
and Luxiel in France, Schlangenbad in Germany and 
Gastein and Tepliz-Schonau in Austria. In this coun- 
try there are a number of such springs which are 
frequented by thousands in the hope of washing away 
some of the "impurities of the system," upon which they 
suppose that skin disease depends. Such are the Hot, 
Warm, and Healing Springs in Western Virginia, also 
Hot Springs in Colorado, Idaho, and California ; but the 



138 DIET AND HYGIENE IN 

ones best known are perhaps those in Arkansas, to which 
thousands flock with syphilis and various skin diseases. 
It is now known, and pretty generally accepted, that 
these springs have in themselves absolutely no curative 
effect on syphilis, but that, as already mentioned, all the 
results ever obtained there are due to the intensive mer- 
curial, and often iodide of potassium, treatment which 
is given at them. It is quite possible that the frequent 
hot bathing enables the system to utilize a larger pro- 
portion of these remedies than is commonly the case at 
home : but it is a fact that few, if any, of those who know 
the disease and its proper treatment best, ever find it 
necessary or wise for patients with syphilis to visit the 
hot springs, while, as has been already detailed, there are; 
many reasons why they should not do so. 

Time forbids our dwelling longer on the subject of 
mineral springs, or the possible advantage or value 
of any of them. I have only given you this list of some 
of the principal ones, and the nature of the waters, that 
you may be better able to judge in case any of your 
patients insist on visiting them. I do not deny that all 
of them have been of service in certain cases, and some- 
times it is wise for patients to visit them in summer, 
instead of going to some less advantageous spot, but 
you can see that it is by no means an unimportant mat- 
ter as to where they should go; and, to tell the truth, if 
just the proper treatment is given them at home it is 
rarely necessary for patients with diseases of the skin 



DISEASES OF THE SKIN 139 

to spend the time and money in such experiments, which 
are so often, or I might say, generally so futile. 

It is so late that only a few words can be given to the 
second part of our subject, namely, the hygiene of dis- 
eases of the skin, as related to others than the patient. 

The impression is very common, among the laity at 
least, that diseases of the skin as a class are contagious 
or at least loathsome, and that precautions should always 
be taken against infection. It is almost needless to re- 
mind you that this is not so, and at my clinical lectures 
you have continually seen me handle every case freely, 
as I have done for forty years, without harm, and with 
the exercise of but very little precaution against con- 
tagion in certain cases. You know that there are really 
very few of the diseases appearing on the skin which are 
contagious or infectious, and that the great mass of 
cases which one sees are as harmless as are those when 
any other organ is diseased : you know that aside from 
the exanthemata (which we will not consider) there are 
hardly half a dozen, out of over a hundred recognized 
cutaneous affections, about which there need ever be any 
thought of contagion ; and, excepting syphilis, the num- 
bers of patients affected with them are relatively few. 

There are, however, a few points which I would like 
to mention, or better, recall to your minds, in regard to 
the few diseases in connection with which any precau- 
tions need ever be taken. 

Syphilis of course comes first, and although with 



i 4 o DIET AND HYGIENE IN 

greater general enlightenment there seem to be fewer 
cases of innocent, extra-genital infection, still the dan- 
ger of this should ever be borne in mind, and patients 
in the earlier stages should always be strenuously cau- 
tioned in regard to the danger of communicating the 
disease to others. This subject is so large that we can 
barely touch upon it, and I must refer you for details 
of the various possibilities of infection to what has been 
fully presented elsewhere. 5 You know, of course, that 
the mere presence of a syphilitic is not dangerous, but 
that there must be the actual transference of the poison, 
directly or indirectly, in order to transport or acquire 
the disease; and even physicians and nurses attending 
such cases, and dressing syphilitic sores, very rarely be- 
come infected, when the nature of the case is known and 
proper precautions are exercised. A badly affected 
syphilitic infant, however, is a pretty dangerous thing, 
and indeed all patients with early syphilis should regard 
themselves for a time as sources of danger, and be on 
their guard against communicating the disease to others, 
mainly through lesions on the mucous membranes. 

The marriage of those who have had syphilis is also 
a great hygienic subject which can hardly be touched 
upon, as also that relating to those who have become 
infected during wedlock. Too much care cannot be ex- 
ercised in these cases : marriage should certainly not be 

5 Bulkley. Syphilis in the Innocent. New York, 1894. 



DISEASES OF THE SKIN 141 

allowed until at least two Wasserman's have been nega- 
tive at intervals of six months, the first taken after 
six months' cessation of prolonged treatment, with 
absolutely no signs of syphilis for the year, without 
treatment. Marital syphilis is unfortunately only too 
common, and it is the duty of the physician to repeatedly 
warn against infection, and in every possible way to 
guard the innocent who may be exposed. 

Scabies is an eruption which is often neglected until 
several members of a family or community are infected, 
when, if proper hygienic precautions are taken this is 
not at all necessary. Prompt and vigorous treatment 
quickly checks the trouble, and thorough boiling and 
disinfection of the clothing prevents its spread: when 
the disease is first suspected protective measures should 
be taken and continued until it is certain that the trouble 
has been fully eradicated. The same is true of pedicu- 
losis, which is sometimes seen in refined circles, and I 
have known head lice to spread through high class 
boarding schools on more than one occasion. 

The vegetable parasitic diseases, ringzvorm and favus, 
may at times present hygienic problems not easy to 
solve. When the former breaks out in an institution 
it will often be most difficult to eradicate, and isolation 
of those affected is necessary. These cases are now 
rightly excluded from our public schools, and at home 
the greatest precautions should be exercised to prevent 



142 DIET AND HYGIENE IN 

its spread, not only by more or less isolation, but also 
by keeping the affected scalp constantly covered with a 
paper cap, which should be burned frequently. 

Tinea versicolor, while it is a parasitic disease, is 
rarely communicated, and practically no precautions are 
necessary against contagion: it is curious to note that 
it is extremely seldom seen in two members of a family, 
and I cannot at the moment recall if I have ever seen it 
on husband and wife. 

Impetigo contagiosa, while it occasionally spreads to 
several children in a family, requires little hygienic care, 
for under proper treatment it commonly yields almost 
at once and seldom recurs. 

Molluscum contagiosum will sometimes appear in 
groups of children, but it is practically non-contagious 
and no special precautions can or need be taken 
against it. 

Tuberculous eruptions, or tuberculides, lupus, etc., 
have so little to do with active tubercle bacilli that there 
is really no danger of contagion, and protective hygienic 
measures are not called for, and I do not know of any 
that are ever attempted. 

There is one disease, manifesting itself on the skin, 
namely, leprosy, about which there has been in times past 
a great deal of unnecessary anxiety in regard to hygienic 
prophylaxis; and it is safe to say that even today the 
known presence of a leper would cause more alarm in 
certain circles than that arising from the presence of 



DISEASES OF THE SKIN 143 

any number of patients afflicted with really contagious 
diseases, including syphilis. 

But those who know most about the disease have no 
fear whatever. You have repeatedly seen cases of true 
leprosy here, which I have lectured on in the clinics, and 
which I have handled as freely as any other patients: 
and this I have done without harm for over forty years, 
often seeing many cases in the year, and on one day I 
examined carefully 236 cases in the Philippines, many 
of them of the most serious, ulcerating types. We have 
constantly admitted cases of true leprosy into this hos- 
pital, in the wards with other patients, now for about 
thirty years, and we, as well as those connected with 
many other institutions, including even leper asylums 
in many countries, testify that authentic instances of the 
contagiousness of leprosy are unknown. 

It may be asked, then, what need is there then of the 
segregation of lepers in asylums ? The same need there 
is of gathering other special groups of diseases, as 
those of the eye, skin, throat, children, female diseases, 
etc., that they may be better cared for, in the most skill- 
ful manner; this is more especially desirable in certain 
communities, because lepers are often poor and are con- 
sidered as outcasts, and so are neglected and totally 
untreated. 

In the light of modern investigation those who know 
most about leprosy do not consider it necessary to place 
restrictions on the patient for the safety of others, in 



144 DIET AND HYGIENE IN 

this country, at least; although it is granted by some that 
food handled by lepers might be the means of conveying 
the bacillus through the stomach, as in the case of fish 
which have become infected, as mentioned in a former 
lecture: but while in Siam I learned of one gentleman 
who for years had had a cook who was a leper. As far, 
however, as relates to contagion by proximity, contact, 
the breath, etc., there is not the slightest danger; and 
thousands of instances can be found, even in leprous 
countries, where wives and husbands have lived for 
years with those affected without becoming diseased, and 
where there are families of healthy children with one or 
the other parent affected with leprosy. 

In bringing this rather long lecture, and this series 
of lectures to a close, I wish to thank you for the close 
attention and interest which has been manifested, even 
when I have had to go over matters familiar to many of 
you, and when I have felt it wise to dwell on other mat- 
ters at what may perhaps have seemed an unnecessary 
lengtH. 

As in my lectures a few years ago on " The Relation 
of Diseases of the Skin to Internal Disorders," 6 I en- 
deavored to make it very clear that one should take a 
very broad-minded view of Dermatology, and not regard 
the skin as aft independent organ and its diseases as local 

6 Bulkley. The Relations of the Skin to Internal Disorders. N. Y., 
Rebman Co., 1906. 



DISEASES OF THE SKIN 145 

affairs; so in these lectures I wanted to broaden your 
horizon yet more, and have you see with me what im- 
mense influence, for good or bad, the matter of diet and 
hygiene may have in connection with many diseases of 
the skin. If I shall have helped any of you to cure some 
of your patients I shall feel amply repaid for the no little 
time and effort it has taken to prepare and deliver the 
present course. 



APPENDIX 



APPENDIX 

SPECIAL DIETS 

In the preceding pages we have examined the prin- 
ciples upon which the dietary treatment of certain 
diseases of the skin should be grounded, and these must 
always be regarded and understood as a basis for the 
proper directing of any special dietary measures. Much 
attention must also be given in regard to individual 
idiosyncrasies, and the general nutrition of the patient. 
Dietary rules should not be ordered carelessly nor in- 
discriminately, but adjusted to each case, quite as care- 
fully as all medicinal remedies: it is well to remember 
the saying that "what is one man's meat is another's 
poison" and also that, with certain limitations, "every 
man is a law unto himself." The matter of diet should 
also be often considered and reconsidered in each special 
case, and inquiry constantly made as to whether it is 
strictly maintained, and also as to its effect on the weight 
and general well being of the patient, ability to do work, 
mental and physical, etc.; otherwise errors are sure to 
occur. 

It is to be remembered also that in all that has been 
said or may be said in regard to dietary regulations, 
they are commonly only one feature of treatment, and 

149 



150 DIET AND HYGIENE IN 

that correct medical measures, internal, external, and 
hygienic, must commonly be employed in conjunction 
with them in order to obtain the best results in diseases 
of the skin. While, as has been shown, correct diet is 
undoubtedly the basis of a proper nutrition, other and 
proper medical treatment is commonly required in order 
that the different organs may perform their functions 
properly. It is too often due to the neglect of these 
common sense precautions that discredit is thrown on 
this or that plan of diet or hygienic measure, which 
when rightly utilized may be of the greatest value. 

We cannot here attempt to present at all fully the 
various dietary theories and regulations which have 
been advanced, many of which have undoubtedly ef- 
fected good results in selected cases in the hands of 
those who have advocated them. The present purpose 
is to set forth lines of diet which practical experience 
for many years has shown to be of value in certain 
cutaneous affections. As it has been shown in the pre- 
ceding pages that the nitrogenous element seems most 
often to be at fault, we will illustrate our subject under 
three heads: ist, Nitrogen-free diet; 2nd, Purin-free 
or largely Vegetarian diet, and 3rd, Light mixed diet. 

I. NITROGEN-FREE DIET. 

Rice boiled in water for half an hour, and then left 
uncovered, to dry out, 15 or 20 minutes. 

Fine white bread, at least twenty-four hours' old. 



DISEASES OF THE SKIN 151 

Butter used freely on the rice and bread, at least 
quarter of a pound daily. 

Water, hot or cold, but not iced, and drank separately 
from food. 

Very thorough mastication is necessary, and half an 
hour should be consumed at each meal ; the rice is eaten 
with a fork, and each mouthful is thoroughly masti- 
cated, and even "fletcherized," that is, not swallowed 
sooner than absolutely necessary, as also the bread. 
This course is followed at each meal, three times daily, 
for five days, in acute inflammatory eruptions, when a 
more varied diet is cautiously returned to; it may be 
repeated with advantage when needed, or in rare in- 
stances may be continued for a much greater time, as 
mentioned in the fourth lecture. 

II. PURIN-FREE OR LARGELY A VEGETARIAN DIET. 

In many systems of vegetarian diet eggs and milk are 
freely allowed, but in the present dietary they are largely 
excluded, with the view of obtaining the necessary 
nitrogenous elements from the vegetable kingdom. The 
only non-vegetarian substance allowed in quantity is 
butter, which represents an almost purely carbohydrate 
product, containing 85 per cent, fat, practically all of 
which is absorbed and utilized. Its very high caloric 
value is well known, one pound of butter, if it could 
be eaten and properly digested, yielding about 3500 
calories, or the full amount requisite for life: although, 



152 DIET AND HYGIENE IN DISEASES OF THE SKIN 

of course, the almost total absence of protein would 
render it an unfit food for complete nourishment. 

Oils and fats may also be freely employed, and a little 
very fat pork, as crisp bacon, or baked with beans, may 
be well added to the diet occasionally, as also a little of 
the fat only of beef and mutton: oil in salad dressing, 
and also even in a little mayonnaise now and then may 
not prove harmful, also table oil may be used on maca- 
roni and spaghetti. Eggs, containing no purin or 
purin-yielding substance, may be occasionally used, but 
in a great moderation, as they have a considerable per- 
centage of protein. The smallest quantity of cheese, as 
a relish, may often be taken with advantage, but most 
cheeses contain a large amount of protein; Fromage de 
Brie having the least, and Neuchatel next. 

It is recognized, as previously stated, that many 
articles of the vegetable kingdom also contain a very 
considerable amount of protein, and under certain con- 
ditions of the system it may be best to use them 
sparingly. Some of the most striking may be again 
mentioned, arranged in accordance with the per cent, of 
protein * in them, with their caloric value, etc. 2 

The fruits have a still lower protein element, but their 
acid properties make them often of doubtful value in 
many diseases of the skin. 

1 The protein element in beef runs from 22 to 30 per cent., mutton and 

lamb 15.5 to 20, chicken and turkey about 21.5, and pork about 19 per cent. 

a Sherman. Chemistry of Food and Nutrition. New York, 191 1, p. 319. 



TABLE I. 
Articles of Food and Their Fuel Value. 



153 



Vegetarian. 



Butternuts 

Black walnuts 

Peanuts 

Peas, dried 

Beans, dried 

Cocoa 

Almonds 

Walnuts, California 

Beans, lima, dried 

Brazil nuts 

Oatmeal 

Entire wheat flour 

Macaroni 

Graham flour 

Wheat flour, average high. . 

" California, fine 

Farina 

Zwieback 

Soda crackers 

Corn meal 

Bread, white, average. ..... 

Barley 

Hominy 

Rice 

Rye flour 

Buckwheat flour 

Chestnuts, fresh 

Figs, dried 

Mushrooms 

Green corn 

Raisins 

Molasses ' 

Beets 

Potatoes, white, raw 

chips 

sweet, raw 

Spinach 

Dates, dried 

Prunes, dried 

Asparagus, cooked 

Cauliflower 

Parsnips 

Onions 

Okra 

Cabbage 

Squash 

Turnips 

Lettuce 

Eggplant 

Olives, green 

Celery 

Carrots 



Protein 
N x 6.25 
per cent. 



27.9 

27.6 

25.8 

24.6 

22.5 

21.6 

21. 

18.4 

I8.I 

17. 

I6.I 

13.8 

134 

13-3 

1 1.4 

7.9 

II. 

9-8 

9.8 

9.2 

9.2 

8-5 

I 3 

6.8 

6.2 

4.3 

3-5 
2.8 
2.6 
2.4 
2.3 
2.2 
6.8 
1.8 
2.1 
2.1 
2.1 
2.1 
1.8 
1.6 
1.6 
1.6 
1.6 
1.4 
1-3 

1.2 
1.2 
I.I 
I.I 
I.I 



Fat 
per cent. 



61.2 

S6.3 
38.6 

I. 

1.8 
28.9 

54-9 
64.4 

1-5 

66.8 

7.2 

1.9 

•9 

2.2 

1. 

1.4 

1.4 

9.9 

9.1 

1.9 

13 

1.1 

.6 

•3 

.9 

1.2 

54 
•3 
4 

1.2 

33 

.1 
.1 

39-8 

•7 

•3 

2.8 

3-3 
•5 
•5 
3 
.2 

•3 
.5 
.2 

•3 
•3 
27.6 
.1 
•4 



Carbohy- 


Fuel value 


drate 


per pound 


per cent. 


Calories. 


3-5 


3065 


II.7 


3001 


24.4 


2490 


62. 


l6ll 


59.6 


1565 


37-7 


2258 


17.3 


2940 


13. 


3182 


65-9 


1586 


7- 


304O 


67.5 


l8ll 


71.9 


1630 


74-1 


1625 


71.4 


1628 


75-1 


l6lO 


76.4 


I58S 


76.3 


1640 



73.5 
73.1 

754 
53-1 
77-8 
79. 
79. 
78.7 
779 
42.1 
74.2 
6.8 
19. 
76.1 

69.3 

l A 
18.4 

46.7 

27.4 

3-2 
78.4 
733 

2.2 

4-7 

135 

99 

U 

9. 

8.1 
2.9 

5.1 
1 1.6 

33 
9-3 



1915 
1875 
1620 
1 182 
1615 
1609 
1620 
1590 
1580 
1098 

1437 
204 

455 
1562 
1302 

180 

37 § 
2598 

558 
109 
1575 
1368 
213 
139 
294 
220 
172 

143 
209 
178 
87 
126 

1357 
840 
204 



Grams to 
yield 100 
Calories 
portion. 

15 
15 
18 
28 
29 
20 
15 
14 
29 
15 
25 
28 
28 
28 
28 
29 
28 
24 



38 
28 
28 
28 
29 
29 

43 

32 

223 

102 

29 

35 

252 

120 

19 

81 

417 

29 

33 

213 

328 

206 
264 

317 
217 
256 
525 
349 
33 
542 
221 



154 DIET AND HYGIENE IN 

A glance at this table shows that all the articles men- 
tioned have a certain percentage of protein, and some of 
them, as the nuts and dried peas and beans, have a very 
large quantity, while oatmeal has also almost as much 
protein as some varieties of meat, as seen in Table II, 
page 1 66; so that in choosing between flesh food and that 
belonging to the vegetable kingdom it is really a choice 
between protein elaborated by animal life or that directly 
obtained from vegetable elements, from which animals 
obtain their protein; for some protein is necessary for 
the system. I cannot now point to any laboratory 
demonstration of just the difference of action between 
animal and vegetable protein on the human frame, but 
clinical experience has abundantly shown that excess of 
the former does often act very prejudicially, while when 
only vegetarian food is taken the system is not all likely 
to obtain more nitrogenous elements than it can well 
manage. 

It is well known that the human system requires 
somewhat definite proportions of the three ingredients 
of food, protein, fat, and carbohydrate, and also that 
a tolerably fixed total of calories daily is required, ac- 
cording to the age and weight of the individual, 
occupation, end to be accomplished, etc. Accordingly, 
in order to maintain perfect nutrition, in some sani- 
tariums it is attempted to regulate the daily amount of 
these proximate principles by means of carefully pre- 
pared menu cards, on which the percentage of each is 



DISEASES OF THE SKIN 155 

affixed to every portion of all the articles served, and 
the patient is desired to adjust the diet according to the 
direction of the physican in charge; the total amount 
of protein, fat, and carbohydrate, in every portion eaten 
is added together, and regulated in such a manner that 
the desired number of calories of each is consumed, and 
that the proper total number of daily calories is ingested. 

This is, of course, quite impracticable in ordinary 
daily life in the home, and is hardly advisable to attempt 
outside of a sanitarium; but the principle remains that 
the nourishment should be adjusted according to the 
needs of the economy, and that a deficient supply of 
either of the three proximate principles of food leads to 
inanition, while an oversupply of the total calories fur- 
nished (which cannot therefore be utilized by the 
system) undoubtedly leads to obstruction in the function 
of some of the organs of life : while too great a disparity 
in the relative proportions of protein, fat and carbo- 
hydrate tends to derangement of the processes of me- 
tabolism, and to consequent disease. 

As remarked in one of the lectures, the ordinary guide 
in health as to the quantity and quality of food and 
drink to be taken is the appetite; but all recognize that 
this may be perverted in various ways, and too often the 
taste is consulted in its place, and the taste is often 
gratified instead of having only the appetite satisfied: 
and it will frequently require a good deal of pluck and 
persistence on the part of both physician and patient to 



156 



DIET AND HYGIENE IN 



institute and carry out faithfully a dietary which will 
remove the morbid conditions present and prevent their 
re-development. To aid in this work an outline of arti- 
cles which may be used in a Purin-free, largely vege- 
tarian diet will be given in the form of daily menus for 
ten days. In many skin affections it is better to make 
the evening meal light, therefore the dinner is placed 
in the middle of the day. 3 

3 These menus are made up in part from the actual daily records pre- 
served by a number of patients who throve for long periods on this diet, 
and faithfully recorded in little books the articles consumed at each meal. 
It is understood that bread, not less than 24 hours old may be used in addi- 
tion at every meal, a couple of slices of ordinary thickness, with plenty 
of butter. A goblet of water, hot or cold but not iced, may be taken with 
each meal, care being taken that each mouthful of food is thoroughly 
masticated, or "fletcherized," and swallowed before any liquid is taken 
into the mouth. 



DISEASES OF THE SKIN 



157 



PURIN FREE OR LARGELY VEGETARIAN DIET. 



Breakfast. 
Postum 

Wheatena and butter 
Hashed brown potatoes 
Toast 
Cut up sweet orange 



First Day. 

Dinner 
Barley soup 

Macaroni with grated cheese 
String beans 
Turnips 
Lemon jelly 

Supper, 
Weak tea 

Corn flakes and cream 
Tea biscuit 
Stewed figs 



Breakfast. 
de Kaffa 

Hominy and butter 
Corn bread 
Stewed prunes 



Second Day. 

Dinner. 
Vegetable soup 
Baked potatoes 
Cauliflower 
French peas 
Lettuce salad 
Bread pudding 

Supper. 
Puffed rice and cream 
Toast 

Graham wafers 
Stewed dried apricots 



158 



DIET AND HYGIENE IN 



Third Day. 



Breakfast. 
Postum 

Rice and butter 
Poached egg on toast 
Breakfast biscuit crackers 
Cantaloupe melon 



Dinner. 
Corn soup 

Spaghetti and grated cheese 
Spinach 
Boiled lentils 
Tomato salad 
Tapioca pudding 



Supper. 
Weak tea 

Grape nuts and cream 
Butter thins" 
Waffles and honey 



Breakfast. 
de Kaffa 

Oatmeal and butter 
French fried potatoes 
Muffins 
Banana 



Fourth Day. 

Dinner. 
Celery soup 
Pork and beans 
Beets 

Boiled cucumbers 
Fruit salad 
Nuts and raisins 



Supper. 
Force and cream 

Toasted crackers and cottage cheese 
Vanilla wafers 
Canned huckleberries 



DISEASES OF THE SKIN 



159 



Fifth Day. 



Breakfast. 
Postum 

Rice and butter 
Very fat crisp bacon 
Graham gems 
Stewed apples 



Dinner. 
Puree of spinach, croutons 
Mashed potatoes 
Lima beans 
Fried parsnips 
Romaine salad 
Hominy pudding 



Supper. 
Shredded wheat and cream 
Lettuce sandwiches 
Lady fingers 
Stewed dried peaches 



Breakfast. 
Postum 

Wheatena and butter 
Hashed brown potatoes 
Sally Lunn gems 



Sixth Day. 

Dinner* 
Chestnut soup 
Stuffed eggplant 
Asparagus 
Brussels sprouts 
Tomato salad 
Dates 

Supper. 
Weak tea 

Post toasties and cream 
ZwiebacK 
Albert biscuit 
Canned cherries 



i6o 



DIET AND HYGIENE IN 



Seventh Day. 



Breakfast. 
de Kaffa 

Corn meal and butter 
Boiled egg 
Creamed potatoes 
Graham rolls 



Dinner, 
Carrot soup 
Mashed potatoes 
Fried tomatoes 
Rutabaga turnips 
Celery salad 
Cup custard 



Supper. 
Toasted rice flakes and cream 
Uneeda crackers 
Rice croquettes 
Sliced oranges 



Eighth Day. 



Breakfast. 
Postum 

Cream of wheat and butter 
Buckwheat cakes and maple 
syrup 



Dinner, 
Asparagus soup 
Stuffed potatoes 
Carrots 
French beans 
Cold slaw 
Figs 



Supper, 
Weak tea 

Toasted wheat flakes and cream 
Tea rusks 
Nabisco wafers 
Apple sauce 



DISEASES OF THE SKIN 



161 



Breakfast. 
Postum 

Petti John and butter 
Scrambled eggs 
Rye bread 
Grapes 



Ninth Day. 

Dinner. 
Cream of barley 
Potatoes browned 
Vegetable oysters 
Baked tomatoes 
Beet salad 
Prune fluff 



Supper. 
Wheat berries and cream 
Oatmeal crackers 
Fruit wafers 
Stewed pears 



Breakfast. 
de Kaffa 
Fried hominy 
Saratoga chips 
Graham bread 
Orange marmalade 



Tenth Day. 

Dinner. 
Sago soup 

Baked sweet potatoes 
Green corn 
Creamed carrots 
Asparagus salad 
Brown Betty 

Supper. 
Ceraline with cream 
Graham bread toast 
Ginger snaps 
Stewed raisins 



i62 DIET AND HYGIENE IN 

In the foregoing menus I have endeavored to include 
about all the articles in the vegetable kingdom, except 
fruits and nuts, which are likely to be properly eaten, 
and a sufficient variety to satisfy many tastes. While 
it is not expected that the diet for each day shall be 
rigidly followed, the attempt has been made to balance 
each day's food so that about the proper proportion of 
protein, fat, and carbohydrates shall be taken, with the 
understanding that white or occasionally graham bread 
at least twenty-four hours' old, and plenty of butter, 
shall be consumed, as desired, with each meal. 

It will be noticed that eggs have been allowed about 
twice in the week, and also fat pork, as bacon or cooked 
with baked beans, about as often. Milk has been largely 
excluded, except as it may occasionally occur in soup 
or custard or puddings, and cream is allowed with the 
evening dry cereal: a little cheese is also occasionally 
added as a relish. In altering these menus care should 
be taken not to derange too much the articles represent- 
ing the different constituents of food: oatmeal, which 
has the highest percentage of protein, should not be 
taken oftener than once or twice a week. Coffee is ex- 
cluded, except as de Kaffa, from which the caffeine is 
largely removed, and tea is allowed only every other 
day, when postum is taken: in place of this latter one 
of the other preparations of cereal coffee may be used, 
but all with very little milk. Water, not iced, may be 



DISEASES OF THE SKIN 163 

taken, a tumblerful with each meal, care being exercised 
not to wash down any food with it. 

A purely vegetarian diet, of course, is not necessary 
to good health, although, as has been shown in previous 
chapters, it is extremely advantageous in some acute 
and chronic affections of the skin, and is invaluable in 
psoriasis. As is well known it has an ever increasing 
number of strong advocates and it has been clearly 
proved that vegetarians have repeatedly gained the vic- 
tory over meat eaters : 4 also that mental activity can be 
greater with a properly regulated vegetarianism. 

III. LIGHT MIXED DIET. 

While it is quite possible, in order to preserve a proper 
"nitrogenous equilibrium/' to secure all the necessary 
nitrogen for the system from the vegetable kingdom 
(as seen in Table I, page 153), it is also true that per- 
fect health can be maintained with the addition of a 
certain amount of animal food, provided the organs and 
tissues can properly digest and metabolize the same. 
Protein is undoubtedly indispensable for the organism, 
and a much larger proportion of it is required in child- 
hood and youth, for the building up of new tissue, than 
in later years. But the ox and the sheep get this from 
the vegetable kingdom and we appropriate their flesh, 
which contains protein in a concentrated form, and the 

*Buttner. A fleshless diet. New York, 1910, pp. 1 18-174. 



164 DIET AND HYGIENE IN 

gratification of the sense of taste for animal food of all 
kinds leads many to take far too much of this highly 
condensed form of nitrogen. 

With the enormous multiplicity of edibles of all kinds 
which are obtainable and often pressed upon one, it is 
difficult to state very definitely in regard to every article 
which might possibly be included in a "light mixed diet." 
And in reference to those with skin affections who do 
not require the first, or "Nitrogen-free diet," or the 
second, "Purin-free or largely Vegetarian diet," some 
one has said, "Find out what agrees with you and chew 
it well, and find out what disagrees with you and 
es-chew it entirely." But even if this can be found out 
individually by patients, they often suffer in many ways 
in the process of making the discovery, and really need 
the guidance of those of wider experience and knowl- 
edge. In regard to most of these matters reference 
must be had to earlier pages in this book, but some 
further general remarks can be made which may be 
of value. 

Alexander Bryce has made an excellent study and 
review of most of the prominent theories of diet, and 
in a final analysis 5 has shown very properly that "the 
only conception which appears to unite them is the 
fundamental doctrine of moderation," which indeed is 
the keynote of all success in alimentotherapy. In good 
health moderation is wise and in ill health it is essential. 

•Bryce. Modern Theories of Diet. N. Y., 1912, p. 333. 



DISEASES OF THE SKIN 165 

When any organ, therefore, as the skin, is at all seri- 
ously affected in its structure, and consequently more 
or less in its function, it behooves one to take just the 
amount and kind of food which will adequately supply 
the demands of the system, and such as will not tax its 
metabolic processes, either by total excess or illy as- 
sorted elements of nutrition. 

The body needs daily for each pound of weight from 
17 to 20 calories, during rest, and from 20 to 25 calories 
during hard work; and these should be in the ratio of 
about one of protein, to three of fat, and six of carbo- 
hydrates. How to adjust these correctly, without re- 
course to actual computation of percentages, as already 
mentioned to be the method in certain Sanitoria, is some- 
times a little difficult; and in health, indeed, it is to a 
certain extent unnecessary, provided the individual will 
remember that the common estimate is that meat should 
constitute about one fourth and vegetable foods three 
fourths of a mixed diet: but as already shown the pro- 
portion of nitrogenous food is often increased far above 
the proper ratio, not to satisfy the appetite but to gratify 
the taste. 

It may be interesting and instructive to note the per- 
centages of protein, fat, and carbohydrate in some of 
the non-vegetarian substances commonly eaten, and also 
the fuel value of the same. The following table is ex- 
tracted from the excellent one furnished by Sherman, 
in his work on "Chemistry of food and nutrition." 



i66 



DIET AND HYGIENE IN 



TABLE II. 
Edible Nitrogenous Nutrients and Their Fuel Values. 



Meats. 



Bacon, smoked 

Beef brisket, medium fat j 

" corned, average 

" roast ! 

" steak, porterhouse 

" " sirloin I 

" sweet breads ; 

" tenderloin j 

" tongue 

Ham, fresh, lean 

" smoked, lean ' 

Lamb, breast ' 

" chops, broiled 

" leg, roast 

Liver, beef 

" calf 

Mutton, f orequarter 

hind " 

leg 

Pork, chops, medium 

" chuck ribs and shoulder 

" sausage 

" tenderloin 

Sausage, bologna 

farmer 

Veal, breast ! 

" cutlet 

" hind quarter 

Poultry 

Chicken 

Duck i 

Fowls 

Turkey 

Fish | 

Black fish \ 

Blue fish 

Cod fish 

" " salt I 

Flounder : 

Haddock 

Halibut steak 

Herring ' 

" smoked ' 

Lobster 






10.5 

15.8 
15.6 

22.3 
21.9 
18.9 
16.8 

16.2 

18.9 

25. 

19.8 

19.1 

21.7 

19.7 

20.4 

19. 

15.6 

16.7 

19.8 

16.6 

17.3 

13. 

18.9 

18.7 

29. 

20.3 
20.3 
20.7 



21.5 

22.3 
19.3 

21. 1 

18.7 
194 
16.5 
254 
14.2 
17.2 
18.6 
19.5 
36.9 
16.4 



(S8. 



64.8 
28.5 
26.2 
28.6 
20.4 
18.5 
12.1 
24.4 
9.2 
14.4 
20.8 
23.6 

29.9 
12.7 

4-5 
53- 
30.9 
28.1 
12.4 
30.1 
31.1 
44.2 

17.6 

42. 

11. 
7-7 
8-3 



2.5 

16.3 
22.9 



i.3 
1.2 

•4 
•3 
.6 

•3 
5-2 

7 '1 
15.8 

1.8 



2 rt 8 



1.7 



2840 
1449 
1353 
1576 
1230 
1099 

799 
1290 

717 
1042 
1209 
1311 
1614 

876 

583 
562 

1543 
1450 
863 
1530 
1585 
2030 

875 
1061 
2240 
817 
683 
715 

493 

824 

1017 

1320 

393 
402 

325 

4 P 
282 

324 

550 

644 

1315 

379 






16 
31 
34 
29 
37 
41 
57 
35 
63 
44 
38 
35 
28 
52 
78 
81 
29 
31 
52 
30 
29 
22 
52 
43 
20 
56 
66 
64 

56 
45 
34 

116 

113 

140 

96 

161 

140 

83 

70 

35 
120 



DISEASES OF THE SKIN 167 

Edible Nitrogenous Nutrients and Their Fuel Values. — Continued. 



Meats 



Fish— continued 

Mackerel 

salt 

Oyster 

" canned 

Salmon 

Shad 

" roe 

White fish 

Sundries 

Calf's foot jelly 

Cheese, American pale. 

red .... 

Cheddar 

" Cottage 

" Full cream , 

" Fromage de Brie. , 

" Neuchatel , 

Pineapple 

Roquefort 

" Swiss 

Cream 

Eggs 

Gelatin 

Milk, condensed, sweetened 

" skimmed 

" whole 





v 


\ 


u . 


•s«1 


a 
u 


2 « 8 


CO 


O X u, 




V.-0 u, 


2— 3"^ 


£zS. 


« 4, 

&H Q. 


u£S. 


£ua6 


18.7 


7-1 ■ 


i 


629 1 


21.1 


22.6 




1305 


6.2 


1.2 


3-7 


228 


8.8 


2.4 


3-9 


328 


22. 


12.8 




923 


18.8 


9-5 




727 


20.9 


3-8 


2.6 


582 


22.9 


6.5 




680 


4-3 


. . . 


174 ! 


394 


28.8 


35-9 


•3 i 


1090 


29.6 


38.3 


... 1 


2102 


27.7 


36.8 


4-1 


2080 


20.9 


1. 


4-3 


499 


25.9 


33-7 


2.4 


1890 


15.9 


21. 


1.4 


1170 


18.7 


274 


1-5 


1484 


29.9 


38.9 


2.6 


2180 


22.6 


29.5 


1.8 


1645 


27.6 


34-9 


1-3 


1945 


2-5 


18.5 


4-5 


883 


134 


10.5 




672 


914 


.1 


. . . 


1660 


8.8 


8.3 


54-1 


1480 


34 


•3 


5-1 


167 


3-3 : 


4. 


5- 


314 



o n . 

2 9 a 



S_. >-•" 

2.2 «o 

ORUft 



72 

35 
199 
138 
49 
61 
78 
67 



115 
23 
22 
22 
9i 
24 
39 
31 
21 
28 
23 
50 
68 
27 
3i 
273 
145 



In turning, therefore, from the first, or the second 
diet just mentioned to a more generous one, one should 
be careful in regard to the introduction of nitrogenous 
elements into the diet, for it will frequently be seen that 
certain eruptions are again aggravated when a too full 
diet is resumed. I am pretty careful not to allow these 
patients to have animal nitrogenous food more than 
once or twice a day, which includes eggs, fish, shell fish, 



168 DIET AND HYGIENE IN 

etc. It is better to have one meal in the day wholly of 
vegetarian products, with butter; and the occasional 
substitution of fish only for the day, as with the Catho- 
lics, conduces to the preservation of health and avoid- 
ance of many skin affections. 

The ill effects of much sweet compounds, in a light 
mixed diet has been already dwelt on, in earlier lectures, 
and the cautions then given in regard to pastry, etc., 
should also be remembered by those who have been sub- 
ject to disorders of the skin. Tea, coffee, and cocoa 
also, if resumed in as great quantity as before may also 
act as a contributory cause in that class of troubles. In 
a word, the vegetarian dietary given earlier in this chap- 
ter is to be regarded as the basis to which small quan- 
tities of protein-bearing animal substances may be 
cautiously added ; but in all respects the thought of mod- 
eration should come uppermost, if it is desired not to 
reproduce the condition of system which led up to the 
skin difficulty. 

A good rule, which has sometimes worked admirably, 
is to have the patient take each meal from only a single 
plate ; in this way one is not likely to take soup, desserts, 
etc. Another less feasible plan suggested by some one 
is that but one single article of food should be taken at 
each meal, irrespective of what that article is. Both of 
these rules put a pretty effective check on gourmandiz- 
ing. A common direction of mine is that the meal shall 
finish with the knife and fork course. 



DISEASES OF THE SKIN 169 

In the light of what has been said in this and preced- 
ing chapters, it is not believed that either meat, fish, or 
eggs should be taken three times daily by those who 
have much tendency to eruptions on the skin ; one meal 
at least should be made wholly on substances from the 
vegetable kingdom, as already mentioned. Nor, in my 
experience, is it desirable to eat eggs every morning 
for breakfast, but to have them alternated with bacon, 
or light fish, etc. Mention has repeatedly been made of 
coffee, and care should be exercised when this is returned 
to in a light mixed diet, after a more abstemious fare. 
Also too free indulgence in acid fruits must be guarded 
against. 

As remarked in earlier chapters, the dietary manage- 
ment of diseases of the skin is yet in a very early stage of 
development, and relatively little definite can be found 
in the text books or in current literature in regard to the 
subject. There is certainly need of much careful ob- 
servation and record, as well as laboratory studies in re- 
gard to the effect of the various possible articles of diet, 
or combinations of articles, upon the skin. 

We recalled at the beginning of the lectures that in 
certain persons at all times, and in other individuals at 
certain times, particular articles of food called forth one 
or another eruption on the skin, as is universally granted. 
What the particular conditions are which render one 
susceptible to the ill effect of perhaps very moderate 



170 DIET AND HYGIENE IN DISEASES OF THE SKIN 

dietary errors at one time and not at another, has not 
yet been at all fully determined, nor why some individ- 
uals can indulge without harm in many articles which 
act most prejudicially on others. It is probable, how- 
ever, that many of the cutaneous reactions, manifesting 
themselves in the various recognized forms of eruption, 
represent anaphylactic phenomena. 

The art and science of medicine in all its branches is 
largely founded on experience, moulded by knowledge 
and judgment, with such confirmation as is possible by 
laboratory and other exact means. In the present lit- 
tle book I have endeavored to present the results of long 
observation and record along certain lines, in one branch 
of medicine, and have sought to explain or confirm some 
of the results of clinical observation by chemical and 
physiological data. While there is still very much in- 
formation and knowledge to be desired in regard to the 
subjects considered, it is believed that what has here 
been presented will be of much practical service in the 
management of many cases of certain diseases of the 
skin which are ordinarily most rebellious to treatment. 



BIBLIOGRAPHY 



BIBLIOGRAPHY l 

1. Atwater and Bryant. — The Chemical Composition of 

American Food Materials. IL S. Department of Agricul- 
ture. Washington, 1906. 

2. Benedict, A. L. — Golden Rules of Dietetics. St. Louis, 

1908. 

3. Bouchard, Ch. — Lectures on Auto-Intoxication in Diseases. 

or Self-poisoning of the Individual. Phila., 1896. 

4. Braithwaite, Alice. — Plainer Fare and Less of it. Lon- 

don, 1908. 

5. Bryce, Alexander. — Modern Theories of Diet, and their 

Bearing upon Practical Dietetics. New York, 191 2. 

6. Bruen, Edward Tunis. — Practical Lessons in Nursing. 

Outlines for the Management of Diet, or the Regulation 
of Food to the Requirements of Health and the Treatment 
of Disease. Phila., 1887. 

7. Buttner, J. L. — A Fleshless Diet. Vegetarianism as a Ra- 

tional Dietary. New York, 1910. 

8. Chittenden, Russell H. — Physiological Economy in Nu- 

trition. An Experimental Study. New York, 1904. 

9. Chittenden, Russell H. — The Nutrition of Man. New 

York, 1907. 
To. Combe, A. — Intestinal Auto-Intoxication. New York, 1910. 

1 No attempt has been made to give an extensive bibliography, which 
might cover many pages, but only a list of the practical working books 
now before me. The various reports from the different Bulletins of the 
U. S. Agriculture Experiment Stations are full of valuable information, 
but they are extensively quoted in the books referred to, which give also 
very many other valuable references. 

173 



174 DIET AND HYGIENE IN 

ii. Dieudonne, A. — Bacterial Food Poisoning, so-called Pto- 
maine Poisoning. New York, 1909. 

12. Einhorn, Max. — Practical Problems of Diet and Nutrition. 

New York, 1905. 

13. Fletcher, Horace. — The New Glutton or Epicure. New 

York, 1909. IV Edition. 

14. Fletcher, Horace. — The A. B. — Z, of our own Nutrition. 

New York, 19 10. VII Edition. 

15. Gibbs, Winifred Stuart.— Food for the Invalid and the 

Convalescent. New York, 191 2. 

16. Gouraud, F. X.— What Shall I Eat? A Manual of Rational 

Feeding. New York, 191 1. 

17. Haig, Alexander. — Diet and Food. London, 1906. VI 

Edition. 

18. Hall, I. Walker. — The Purin Bodies of Food Stuffs. And 

the Role of Uric Acid in Health and Disease. Philadelphia, 
1903. II Edition. 

19. Hall, Winfield S.— Nutrition and Dietetics. New York. 

1911. 

20. Hutchison, Robert. — Food and the Principles of Dietetics. 

New York, 1910. Ill Edition. 

21. Jordan, Whitman H. — Principles of Human Nutrition. A 

Study in Practical Dietetics. New York, 1912. 

22. Kellogg, Ella Eaton. — Science in the Kitchen, Principles 

of Healthy Cookery. Battle Creek, Mich., 1910. 

23. Locke, Edwin A. — Food Values. Practical Tables for use 

in Private Practice and Public Institutions. London, 191 1. 

24. Lorand, Arnold. — Health and Longevity through Rational 

Diet. Philadelphia, 1912. 

25. Lusk, Graham. — The Elements of the Science of Nutrition. 

Philadelphia, 1909. 



DISEASES OF THE SKIN 175 

26. McCay, Major D. — The Protein Element in Nutrition. 

London and New York, 191 2. 

27. Murray, J. Alan. — The Economy of Food. A Popular 

Treatise on Nutrition, Food and Diet. New York, 191 1. 

28. Pattee, Alida Frances. — Practical Dietetics with Refer- 

ences to Diet in Diseases. New York, 1910. VI Edition. 

29. Pavy, F. W. — A Treatise on Food and Dietetics. Physiolog- 

ically and Therapeutically Considered. New York, 1881. 
II Edition. 

30. Roberts, Sir William. — Lectures on Dietetics and Dys- 

pepsia. London, 1886. II Edition. 

31. Sherman, Henry C. — Chemistry of Food and Nutrition. 

New York, 191 1. 

32. Smith, G. Carroll. — What to Eat and Why. Philadelphia, 

1912. 

33. Snyder, Harry. — Human Foods, and their Nutritive Value. 

New York, 191 1. 

34. Sutherland, G. A. — A System of Diet and Dietetics. Lon- 

don, 1908. 

35. Thompson, Sir Henry. — Diet in Relation to Age and Ac- 

tivity. London, 1887. 

36. Thompson, W. Gilman. — Practical Dietetics, with Special 

Reference to Diet in Disease. New York, 1909. IV Edi- 
tion. 

37. Tibbles, William. — Foods, their Origin, Composition and 

Manufacture. London, 1912. 

38. Wallace, J. Sim.— The Role of Modern Dietetics in the 

Causation of Disease. London, 1912. 

39. Watson, Chalmers. — Food and Feeding in Health and Dis- 

ease. New York, 191 2. 



INDEX 



INDEX 



PAGE 

Absence of certain articles in the diet influencing skin and 

other diseases 9 

Absorption from the intestine 116 

of milk, without caseation 48 

versus the digestion of milk 50 

Acne from dietary indiscretions 7 

harmed by even moderate use of alcoholics 39 

juvenilis from erroneous diet, rather than from age 88 

largely dependent on diet 87 

rosacea greatly aggravated by occupation 122 

illustrating harm from alcohol 38 

kept up by ale and beer 91 

Moselle wine 91 

the most important skin disease regarding diet 92 

Activity and age, nutritive elements according to 25 

Acute eczema checked by rice diet 70 

in relation to diet 6y 

Afternoon tea keeping up acne 91 

Age and activity, diet in relation to 57 

nutritive elements according to 25 

Aggravation of some skin diseases by massage 121 

Alcohol, effect on diseases of the skin 36 

mode of action on the skin 37 

prejudicial in psoriasis 105 

Alcoholic drinks affecting skin diseases 7 

rendering acne incurable 91 

Alcoholics inducing attack of psoriasis 8 

179 



180 INDEX 

PAGE 

Ale producing acne indurata 91 

"Alkaline tide" in the stomach 50 

relation to proper taking of milk 50, 53 

Alkaline waters 134 

Alopecia influenced by diet 109 

Anaphylaxis explaining idiosyncrasies in regard to dietetic 

matters 170 

Appendix 149 

Appetite and taste 155 

distinction between 10 

should be the proper guide to diet 10 

Arsenical waters 136 

Arthritis deformans relieved by rice diet 70 

Asthma affected by rice diet 67 

Athletic contests won by vegetarians 27, 60 

Atmospheric conditions affecting skin diseases 123 

Balance of protein, fat, and carbohydrate in food 162 

Bandage, solid rubber, in eczema and ulcer of leg 123 

Bathing frequently harmful in many diseases of the skin. . . 126 

in connection with diseases of the skin 125 

sea, benefit and harm from 128 

Baths, medicated, in diseases of the skin 127 

mercurial, frequent harm from 127 

sulphur, frequent harm from 127 

Turkish and Russian, harm from 127 

in diseases of the skin 127 

Beans, peas, and lentils, large amount of protein in 28 

"Beef, poor man's," or beans, peas, and lentils 28 

Beer producing acne indurata 91 

Beverages, harm from many commonly used 46 

Bibliography 173 

Boils, carbuncles, and pus infections relatively rare, depend- 
ent upon condition of system 4 

Bowels, regularity in action of the 1 14 

Bread, percentage of protein in 73 

Breakfast, importance of emptying bowels after 116 



INDEX 181 

PAGE 

Bromo-iodine waters 137 

Butter, caloric value of 73, 151 

Caffeine, poisonous effects of 34 

Calories per pound in various vegetarian products 153 

nitrogenous substances 166 

amount required daily, per pound of body weight 165 

of energy, proportion in pure sugar 32 

Cancer, rarity of in rice eating countries 94 

Carbohydrates and fats, function of 26 

content of different chocolates 35 

vegetarian articles of food 153 

protein, fats, mineral salts, and water in proper propor- 
tion, necessary for good nutrition 24 

Care necessary in resuming mixed diet 167 

Cause, underlying, of diseases of the skin 4 

Causes of disturbance of sleep 118 

Caviar, probable means of communicating leprosy 30 

Cheese, chemical analysis of 167 

often harmful in diseases of the skin 31 

Chemical composition of wheat j6 

Chemistry of foods, supporting dietetic studies vii 

Chewing food, importance of 15 

Chicken, chemical analysis of 166 

Chocolate, great variance in chemical composition of different 

brands 35 

in relation to diseases of the skin 35 

Clothing in relation to diseases of the skin 124 

Chronic eczema often removed by vegetarian diet 83 

representing lowered vitality 66 

Claret wine delaying cure of eczema 66 

Climate and seasons affecting psoriasis 93 

Cocoa in relation to diseases of the skin 35 

Coffee, containing xanthin, excluded in vegetarian diet 162 

in relation to diseases of the skin 34 

Constipation, evils resulting from 115 

Contagiousness of diseases of the skin 139 



182 INDEX 

PAGE 

Cooking, importance of proper, in many eruptions 56 

Cost, increased, of food dependent in part upon increased 

consumption in recent years 17 

of food under "Fletcherism" 17 

Cream, chemical analysis of 167 

"Cure" at mineral springs 131 

Daily menus for vegetarian diet 157 

Danger signals from the skin 25, 58 

Dates, low protein and high carbohydrate, contents of 33 

Defecation immediately after breakfast, importance of.... 116 

Dermatitis herpetiformis affected by diet 107 

herpetiformis following deficient excretion of urea. .... 101 

Diet affecting acne 88 

effect of in f urunculosis 108 

lichen planus 107 

many skin diseases 106 

in dermatitis herpetiformis 107 

pemphigus 107 

relation to age and activity 11, 57 

urticaria io 7 

influencing alopecia 109 

epithelioma IQ 8 

syphilis I0 9 

mode of influencing diseases of the skin 9 

only one side of therapeutics no 

to be carefully adjusted to each case 149 

Dietary indiscretions causing acne 7 

Dieting in skin diseases, definition of 1 1 

not a brief, spasmodic effort n 

Diets for special diseases x 49 

Digestion, relation of to proper taking of milk 53 

Disadvantages of attempted "cures" at mineral springs 132 

Diseases of the skin affected by proper use of milk 55 

how influenced by diet 9 

Dried fruits, in relation to vegetarian diet 33 

Duck, chemical analysis of J 66 



INDEX 183 

PAGE 

Duration of rice diet 70, 74 

vegetarian diet in psoriasis 97 

Eating, irregular, harmful in skin diseases 19 

rapidly a cause of acne 89 

harmf ulness of 14 

Economic nutrition of Mr. Fletcher 17 

Eczema, acute, in relation to diet 67 

aggravated by bad clothing 124 

as influenced by diet 66 

chronic, dependent on lowered vitality 66 

often removed by vegetarian diet 83 

erythematous, greatly aggravated by occupation 122 

harmed by even moderate use of alcoholics 39 

infantile, dietary treatment of 75 

reflects totality of life of the individual 87 

Eggs allowed in moderation with vegetarian diet 162 

chemical analysis of 167 

purin free, may be used in moderation 152 

Energy value of food required much less under perfect mas- 
tication 16 

Enormous increase of food consumed per capita in the United 

States in the last ten years 17 

Epithelioma influenced by diet 108 

rarity of in rice-eating countries 94 

Error in exercising when fatigued mentally 120 

of claim of Passavant's meat cure for psoriasis 99 

Errors in diet in eczematous children 81 

Eruptions connected with deranged metabolism 6 

increased by chocolate 35 

resulting from dietary causes 7 

Erythema multiforme checked by rice diet 69 

resulting from food eaten 7 

Evils resulting from constipation 115 

Excess of food commonly taken 16 

Excessive meat eating, effect on structure of the skin 102 

Exclusion of exogenous protein 68 



184 INDEX 

PAGE 

Exercise, harm from too violent or prolonged 120 

harmful when greatly fatigued mentally 121 

in connection with skin diseases 120 

Fat content of fish 166 

meats 166 

poultry 166 

vegetarian articles of food 153 

Fatigue influencing eruptions 19 

Fats, protein, carbohydrates, mineral salts, and water, in 

proper proportion, necessary for food nutrition 24 

varying content of different chocolates 35 

Faulty nitrogenous metabolism cause of psoriasis 101 

Favus, precautions against 141 

Feeding, too frequent, a cause of infantile eczema 80 

Ferruginous waters 136 

Figs, low protein and high carbohydrate contents of 33 

Fish, fat content of 166 

fuel value per pound, in calories 166 

in relation to diseases of the skin 28 

means of communicating leprosy 29 

protein or nitrogenous content of 166 

some varieties harmful in skin eruption 28 

Fletcher, Mr. Horace, importance of his work 15 

"Fletcherism" 15 

important in acne 89 

importance of 23 

"Fletcherize" 15 

Food causing erythema and urticaria 7 

eaten certainly of importance in skin diseases 13 

Forced feeding often a mistake in skin diseases 13 

Fowls, chemical analysis of 166 

Fruits in relation to diseases of the skin 32 

objection to in diseases of the skin 152 

protein content of 152 

Fuel value of fish, per pound, in calories 166 

meats, per pound, in calories 166 



INDEX 185 

PAGE 

Fuel value of poultry, per pound, in calories 166 

vegetarian articles of food, per pound in calories. . 153 

Furunculosis affected by diet 108 

Gelatin, chemical analysis of 167 

Harm from too violent or prolonged exercise 120 

Haste in eating, harmfulness of 14 

Hebra, Professor, views in regard to bathing 126 

Hebra's view of Passavant's claim of meat cure for psoriasis 99 

Hot springs 137 

Hygiene in diseases of the skin 113 

of eruptions as related to others than the patient 139 

Iced water keeping up acne 90 

Imperfect mastication, harmfulness of 14 

Impetigo contagiosa, seldom requires hygienic care 142 

Importance of daily bowel action 114 

Improper mastication a cause of acne 89 

Increase, enormous, of food consumed per capita, in the 

United States in the last ten years 17 

Index 179 

Indifferent or pure mineral waters 133 

Indirect effect of occupation on diseases of the skin 121 

Infantile eczema, dietary treatment of 75 

Infectiousness of diseases of the skin 139 

Influence of diet, mode of, in skin diseases 9 

Insalivation, inadequate, harmfulness of 14 

thorough, importance of 16 

Intestinal absorption, poisoning from 116 

fermentation caused by dietary errors 12 

Irregular eating harmful in skin diseases 19 

Iodo-bromine waters 137 

Iron waters 136 

Jelly, calf's foot, chemical analysis of 167 

"Jelly, wheat" in infantile eczema 75 



186 INDEX 

PAGE 

Kidneys seek to keep arterial blood in a state of physiological, 

nitrogenous equilibrium 103 



Leg ulcer affected by occupation 123 

Lentils, peas, and beans, large amount of protein in 28 

Leprosy, authentic cases of contagiousness unknown 143 

freely admitted in wards of hospitals 143 

no danger from ordinary proximity 144 

not actively contagious 142 

possibly acquired by eating caviar 30 

spread through eating fish infected with the leprosy bac- 
illus 29 

Lichen planus affected by diet 107 

Light mixed diet 163 

Lobster, chemical analysis of 166 

Local pathology and treatment versus internal viii 

Lupus, not actively contagious 142 

Many cutaneous affections influenced by diet 65 

Marital syphilis 141 

Marriage and syphilis 140 

Massage, poor substitute for voluntary exercise 121 

skin diseases often aggravated thereby 121 

Mastication, improper, a cause of acne 89 

imperfect, harmfulness of 14 

perfect, reducing the total energy value of food required 

by one-half 16 

thorough, importance of 16 

Meat cure for psoriasis, Passavant 98 

excessive, effect on growth and reproduction 102 

structure of the skin 102 

use of, effect on animal tissues 26 

Meats, fat content of 166 

fuel value per pound, in calories 166 

protein or nitrogenous content of 166 

Medicated baths in diseases of the skin 127 



INDEX 187 

PAGE 

Mental influences, effect on eruptions, largely through the di- 
gestive system 18 

Menu, daily for vegetarian diet 157 

Mercurial baths, frequent harm from 127 

Metabolic errors indicated by the urine 6 

Metabolism affected by diet 6 

as affecting skin diseases 5 

when perverted causing disease 5 

Microorganisms require a suitable soil 4 

Milk, avoidance of food while taking 52 

causing "biliousness" 48 

chemical analysis of 167 

direct absorption of 48 

effect of when rightly taken 49 

harm from when wrongly taken 47 

largely excluded in vegetarian diet 162 

mother's, often at fault in infantile eczema 80 

reasons why it often disagrees 48 

relative value of in calories 54 

results from properly taking 52 

temperature of, when rightly taken 51, 53 

wrongly taken, harmful in acne 90 

Mineral salts, protein, carbohydrates, fats, and water in 

proper proportion, necessary for good nutrition 24 

springs, classification of 133 

disadvantages connected therewith 131 

"good for diseases of the skin" ? 128 

list of, and indications for use of I 33 _I 38 

rarely needed for diseases of the skin 138 

real value of 131 

reasons for inemcacy of 130 

useless or harmful in many eruptions 128 

Mode of influence of diet in skin diseases 9 

Moderation in eating essential to health 168 

the fundamental doctrine, in diet 164 

wise in health, essential in ill health 164 

Molluscum contagiosum, not actively contagious 142 



188 INDEX 

PAGE 

Mouth, digestion begins in the 14 

Mother's milk often at fault in infantile eczema 80 

Mycosis fungoides affected by diet 108 

Nervous shock, effect on eruptions, largely through the di- 
gestive system 18 

Nitrogen-free diet 150 

or rice diet 69 

Nitrogenous content of different chocolates 35 

elements excluded from diet 68 

equilibrium of system 103 

food limited to once or twice daily 167 

metabolism, faulty, cause of psoriasis 101 

Nutrition, factors of good and bad 24 

good and bad, relation to eruptions 24 

Nuts causing crop of acne lesions 88 

protein percentage in 31 

in relation to diseases of the skin 31 

Obstipation, evils resulting from 115 

Occupation as affecting diseases of the skin 121 

Overeating an error in many with diseases of the skin 12 

Oysters, chemical composition of 167 

Passavant's so-called meat cure for psoriasis 98 

Peas, beans, and lentils, large amount of protein in 28 

Pediculosis, precautions against 141 

Pemphigus affected by diet 107 

Personal character of this book vii 

Physio-pathological basis for a vegetarian diet in psoriasis. . 100 

Pityriasis versicolor, not ordinarily contagious 142 

"Poor man's beef," or beans, peas, and lentils 28 

Pork, fatty, allowed in moderation in vegetarian diet 162 

Poultry, fat content of 166 

fuel value per pound, in calories 166 

percentage of protein in 28 

protein or nitrogenous content of 166 



INDEX 189 

PAGE 

Practical working out of vegetarian diet 104 

Protein, amount required by the human frame 26 

carbohydrates, fats, mineral salts, and water, in proper 

proportion, necessary for good nutrition 24 

content of bread 73 

poultry 166 

vegetarian articles of food 153 

element in beans, peas, and lentils 105 

excessive in diet, causing psoriasis 60 

excess of, effect on animal tissues 26 

harm from 25 

exogenous, exclusion of 68 

fat, and carbohydrate, importance of maintaining an ap- 
proximate proportion of each in diet 155 

in diet influencing psoriasis 8 

large amount in beans, peas, and lentils 27 

metabolism, injurious effects of products of 26 

obtained by animals from vegetarian products 163 

or nitrogenous content of fish 166 

meats 166 

percentage of in dried beans, peas, and lentils 28 

fish 28 

nuts 31 

poultry 28 

vegetable 154 

in vegetarian products 26, 153 

Prunes, low protein and high carbohydrate contents of 23 

Pruritus aggravated by spices 30 

Psoriasis, analysis of 140 cases on vegetarian diet 94 

benefited by rice diet 71 

cannot be cured by sulphur or other waters 135 

caused by excess of protein in diet 60 

faulty nitrogenous metabolism 101 

disappearance of lesions under an absolutely vegetarian 

diet, with no other treatment 94 

duration of vegetarian diet 97 

eruption increased by indulgence in dried beans and peas 28 



iqo INDEX 

PAGE 

Psoriasis, exhibiting markedly the effect of diet 92 

harmed by even moderate use of alcoholics 39 

influenced by protein in diet, 8 

Passavant's claim of a meat cure 98 

rarity of in the Far East 93 

rice-eating countries 94 

warm climates explained on dietetic reasons ....... 94 

reasons for recurrence of while under a supposed vege- 
tarian diet 96 

Pure or indifferent mineral waters 133 

"Purifying the blood" by baths, error regarding. 127 

Purin bodies indicating metabolism of cell nuclei 102 

free or largely a vegetarian diet 151, 157 

not found in eggs 152 

Pus cocci, while omnipresent, affect but few 4 

infection dependent on condition of the system 4 



Quality of food affecting skin eruptions 13 

Quantity of food, often too great 12 

Raisins, low protein and high carbohydrate contents of 33 

Rapid eating a cause of acne. 89 

harmfulness of 14 

Rarity of psoriasis in the Far East 93 

warm climates explained on dietetic reasons 94 

Rationale of operation of the rice diet 6j, J2 

"wheat jelly" preparation. 79 

writer's method of giving milk. 49 

Raw fruits sometimes harmful in skin diseases 32 

Reasons for recurrence of psoriasis while under a supposed 

vegetarian diet 96 

Rebelliousness of many skin diseases indicates underlying 

cause, probably dietary 4 

Re-creation secured by rest 119 

wrong understanding of 119 

Recurrence of psoriasis under vegetarian diet 96 



INDEX 191 

PAGE 

Regularity in hours of sleep, importance of 1 17 

of life 113 

Relative proportion of animal and vegetable food compatible 

with health 165 

Rest before meals, with milk treatment 119 

importance of in certain dermatoses 119 

at proper times 19 

Results of proper taking of milk 52 

ultimate, of vegetarian diet in psoriasis 106 

Return to ordinary diet, after rice diet 74 

Rheumatism benefited by rice diet 71 

Rhinophyma resulting from alcohol 39 

Rice diet 150 

description of 71 

details concerning 72 

duration of 70, 74 

in acute inflammatory diseases 69, 70 

Ringworm, precautions against 141 

Rubber bandage, solid, in eczema and ulcer of leg 123 

Russian baths in diseases of the skin 127 

Saliva, importance of in digestion 14 

Saline waters 134 

Scabies, contagiousness of 141 

skin often irritated by sulphur baths 128 

Scorbutus, illustrating effect of dietary error 7 

Scientific basis for dietetics 7 

Scurvy, illustrating effect of dietary error 7 

Sea bathing, benefit and harm from 128 

Sedentary life leading to cutaneous disease 121 

Shell fish, in relation to diseases of the skin 30 

Signal flags of danger from the skin 25, 58 

Sleep, causes of disturbances of 118 

in its relation to diseases of the skin 117 

Soda water, harmful in acne 90 

Soup, harmful in acne 91 

Special diets 149 



192 INDEX 

PAGE 

Spiced foods, relation to diseases of the skin 30 

Springs, hot . . . . . . * 137 

mineral, "good for diseases of the skin" ? 128 

list of , and indications for use of 133-138 

useless or harmful in many eruptions 128 

Stercoremia, evils of 1 16 

Substitutes for tea, coffee, etc 36 

Sugar and milk in relation to diseases of the skin 36 

food value of,, percentage of calories in 32 

Sulphur baths, frequent harm from 127 

waters 135 

Susceptibility to microorganisms 4 

Sweets, often harmful in diseases of the skin 31 

Syphilis and marriage 140 

contagiousness of 140 

harmed by any form of alcoholic drink 38 

ill results following visits to mineral springs 132 

influenced by diet 109 

reasons for benefit at hot springs 138 

treated by mercurial baths 128 

Wasserman's test, before marriage 141 



Table I, fuel value of vegetarian articles of food 153 

II, edible nitrogenous nutrients, and their fuel values. . . 166 

Taste and appetite 155 

gratified after appetite is satisfied 10, 12 

Tea in afternoon keeping up acne 91 

relation to diseases of the skin 33 

Teeth, part played by them in digestion 16 

Teetotalism imperative in syphilitic patients 38 

Thermal waters 137 

Time and method of eating important 14 

Tinea versicolor, not ordinarily contagious 142 

Tobacco influencing eczema badly 66 

Tuberculous eruptions, not actively contagious 142 

Tuberculides, not actively contagious 142 



INDEX 193 

PAGE 

Turkish baths in diseases of the skin 127 

Turkey, chemical analysis of 166 

Ulcer of leg affected by occupation 123 

treated by solid rubber bandage 123 

Ultimate results of vegetarian diet on psoriasis 106 

Underlying cause of diseases of the skin 4 

Urinalysis, volumetric, as a means of discovering metabolic 

errors 7 

Urine, condition of, indicating metabolic errors 6 

indication of nitrogenous equilibrium 103 

in psoriasis 101 

Urticaria, effect of diet 107 

resulting from food eaten 7 

Vegetable protein 154 

in vegetarian products 26, 153 

Vegetarian diet 151 

advantage of 60 

in psoriasis 61 

analysis of 140 cases 94 

often best for chronic eczema 83 

practical working out 104 

sufficient for all needs of the body 27 

products, varying proportion of protein in 26 

Vegetarianism, athletic contests won by 60 

benefits resulting from 2y t 60 

value of in certain skin diseases 27 

Vinegar in relation to diseases of the skin 30 

Washing down food, harmfulness of 15 

Wasserman's test for syphilis, before marriage 141 

Water, amount in the human body 43 

required in health during 24 hours 44 

essential to proper working of the system 43 

hot, value of in certain eruptions 46 



194 INDEX 

PAGE 

Water, iced, harm from 45 

protein, carbohydrates, fats and mineral salts, in proper 

proportion, necessary for good nutrition 24 

value of internally in certain skin affections 45 

"Wheat jelly" in infantile eczema 75 

preparation of 78 

superior to advertised foods yy 

Xanthin contained in coffee and cocoa harmful in psoriasis. 105 
Xanthoma diabeticorum accompanying glycosuria 101 



m 22 1913 



